
ifel 





Class. 



Book 



COPYRIGHT DEPOSIT 



VENEREAL DISEASES 



THEIR 



COMPLICATIONS AND SEQUELS 



BY 

EDWARD L. KEYES, A.M., M.D. 

Late Professor of Dermatology and Genito-Urinary Surgery in the Belleviie 

Hospital Medical College ; Consulting Surgeon to 

Bellevue Hospital, etc., etc. 

AND 

CHARLES H. CHETWOOD, M.D. 

Professor of Genito-Urinary Surgery in the New York Polyclinic College 

and Hospital ; Visiting Surgeon to Bellevue 

Hospital, etc. 



Illustrated by Eight Full-page Plates in Black and Colors and 
One Hundred and Seven Engravings 



NEW YORK 
WILLIAM WOOD AND COMPANY 

MDCCCC 



TWO COPIES RECEIVED, 

L Ibrary of Congr©8% 
Office of the 

FF" 54 1900 

Kegistsr of Copyrights^ 






54386 



Copyright, 1900 
By WILLIAM WOOD AND COMPANY 



SliOOhD G0PV# 






THE PUBUSHERS' PRINTING COMPANY 
NEW YORK 



PREFACE. 



A FORMER work of identical title, from the pen of the senior author of 
this volume, appeared in January, 1880, twenty years ago, as one of 
" Wood's Library." It had two objects in view, both of which have been 
accomplished. 

The first object was to combat the then raging furor for anterior ure- 
throtomy which possessed the younger members of the profession. This 
is now happily over, and a certain amount of good has followed the ex- 
cess. Strictures of the pendulous urethra are understood and managed 
better to-day than twenty years ago. 

The second and most important object was to disseminate the author's 
teachings upon the treatment of syphilis. This tonic treatment, by the 
prolonged mild use of mercury in such a way as to do the patient no harm 
while his malady was being mastered, is to-day so widely spread and so 
well understood, and has been accepted so largely, if judgment be ren- 
dered according to the evidence at command, that there is no reason to 
make any radical change, in so far as syphilis is concerned, in the presen- 
tation of this subject. 

But that book has long since ceased to be a safe guide in its urethral 
teachings on account of the strides made in bacteriology and therapeutics 
during the last decade. 

The younger blood of the junior author and his point of view, together 
with a general growing experience, have revolutionized many of the ideas 
advanced in the former treatise, and the time has seemed ripe to us to join 
hands in authorship for the purpose of placing the result of our com- 
bined experience before the profession in a practical way. 

This volume is the result. 

In it is reproduced the senior author's original teaching concerning 
chancroid and syphilis, the latter practically in the whole piece making 
little change further than to cut out references and cases to reduce the 
volume of the text, but the chapter on chancroid has been reconstructed. 

A valuable chapter on nervous syphilis has been contributed by Dr. 
Pearce Bailey, consulting neurologist at St. Luke's Hospital, and to him 
the authors render public acknowledgment. Dr. Chetwood, the junior 
author, has so entirely remodelled and rewritten that portion of the book 



VI PREFACE. 

relating to the urethra that it has seemed proper to place this section 
first and to issue the volume as a new book rather than under the name of 
a second edition of the old book. 

The authors' warm thanks are extended to Dr. F. M. Jeffries, direc- 
tor of the laboratory of the New York Polyclinic College and Hospital, 
for excellent work in collecting references and assisting in preparing the 
section on the Bacteriology of Urethritis. To Dr. A. F. Btichler we are 
indebted for clinical material, and to Dr. D. A. Sinclair for various good 
offices. E. L. Ketes. 

C. H. Chetwood. 

109 East Thiktt-Foukth Street, 
New York, January, 1900. 



CONTENTS. 



PAGE 

Introduction, . . ix 

PART I. 

Acute and Chkonio Urethritis. Complications and Sequels. 

chapter i. 

Specific and Non-Specific Urethritis : Gonorrhoea. Definition, Etiology, Bac- 
teriology, Symptoms, Diagnosis, Duration, Treatment, .... 3 

CHAPTER 11. 

Chronic Urethritis : Etiology, Pathology, Symptoms, Diagnosis, Treatment, . 37 

CHAPTER III. 
Balanitis and Posthitis — Herpes Progenitalis — Venereal Warts, . . . .54 

CHAPTER IV. 

Inflammation of Urethral Follicles — Peri-urethral Abscess — Cowperitis — Pros- 
tatitis — Seminal Vesiculitis, .... o .... 68 

CHAPTER V. 
Acute and Chronic Cystitis — Epididymitis, 89 

CHAPTER VI. 

Stricture of the Urethra, 107 

CHAPTER VII. 

Gonorrhceal Rheumatism — Non-specific Affections of the Eye — ^Purulent Oph- 
thalmia, 157 

PART II. 

Chancroid and Syphilis, 
chapter i. 

Chancroid : Definition, Etiology, and Clinical History, 167 

CHAPTER II. 
Chancroid {Continued) : Diagnosis, Prognosis, and Treatment, .... 177 



Vill CONTENTS. 

CHAPTEB m. 

PAGE 

The Complications of Chancroid, , , . 186 

CHAPTER IV. 
Syphilis : Definition — Origin— Course— General Pathology, . , . . 198 

CHAPTER V. 
The Transmission of Syphilis : Methods of Contagion— Prognosis, c . . 203 

CHAPTER VI. 
The Chancre — Primary Lesion of Syphilis, c .211 

CHAPTER Vn. 
Constitutional Syphilis — Stages of the Disease, ....... 220 

CHAPTER VIIL 
The General Treatment of Syphilis, ......,,, 224 

CHAPTER IX. 
The General Treatment of Syphilis (Continued)^ . . . • , . . 251 

CHAPTER X. 
Syphilis of the Skin, 261 

CHAPTER XI. 
Syphilis of the Mucous Membranes, Lymphatic Glands, Hairy Parts, and Nails, 284 

CHAPTER XII. 
Syphilis of Muscles, Tendons, and Aponeuroses, Bursas, Joints, and Bones, . 292 

CHAPTER XIII. 
Syphilis of the Viscera, 302 

CHAPTER XIV. 
Syphilis of the Nervous System, 812 

CHAPTER XV. 
Syphilis of the Genito-Urinary Organs in Both Sexes, ..... 324 

CHAPTER XVI. 
Syphilis of the Eye and Ear, 330 

CHAPTER XVIL 
Inherited Syphilis, . . .336 



INTRODUCTION. 



A STEICT application of the title of this treatise should include only 
-^^^ those diseases acquired during sexual intercourse and starting in the 
sexual organs. But these maladies may by direct contagion make their 
initial appearance elsewhere, and through their complications and sequelae 
invade the adjacent organs or involve remote parts of the body. 

Of the three principal divisions of venereal disease — syphilis, chan- 
croid, and gonorrhoea — the first two commonly appear upon the external 
genitals, while the last is essentially a disease of the urethra, and is, on 
account of its microbic origin, otherwise known as specific urethritis. 

Each of these maladies is distinct from the other etiologically, path- 
ologically, and clinically. All of them are virulent and contagious, and 
while they never arise de novoy yet in the case of chancroid and gonor- 
rhoea there exist spurious examples which bear so close a resemblance to 
the real malady that the difference is only bacterial, and the selection of 
treatment must depend upon a knowledge of this fact. These spurious 
cases are of idiopathic origin and may be non-venereal in their nature, 
but as they are frequently acquired during the sexual act and so closely 
resemble their prototypes as often to be mistaken for them, their con- 
sideration becomes a necessity in a work upon venereal diseases. The 
same remark applies also to the complications and sequelae of the vene- 
real diseases. These latter are not confined to the genital regions, but 
include, through contiguity, the neighboring organs and, by reinoculation 
and metastases, remote parts of the body. 

Finally, syphilis is not a disease of any organ or of any region, but 
of every tissue in the body and of the blood as well. Hence the title 
venereal refers only to the source from which these several maladies and 
their complications are derived and to the customary location of the pri- 
mary lesions occasioning them ; but as the name is sanctioned by time and 
custom it must be retained, although entirely too narrow to indicate the 
scope of a treatise which a proper consideration of the group of maladies 
involved necessarily calls for. 



PART I. 

ACUTE AND CHRONIC URETHRITIS. 

COMPLICATIONS AND SEQXJELjE. 



VENEREAL DISEASES. 



CHAPTER I. 

SPECIFIC AND- NON-SPECIFIC UEETHEITIS— GONORKHCEA. 

Definition and Etiology. 

The term urethritis, without qualification, signifies inflammation of 
any portion of the urethral canal. Such inflammation is designated, 
according to its cause, specific or non-specific ; according to its locality 
anterior or posterior ; and, according to its duration, acute or chronic. 

Specific urethritis, commonly spoken of as gonorrhcea, is, in the male, 
an intense urethral inflammation, characterized by a period of incubation, 
and by a profuse discharge of pus which possesses virulent qualities, due 
to the presence of a diplococcus — the gonococcus of Neisser. 

This definition at once places gonorrhoea in the rank of virulent dis- 
eases. It has a period of incubation, runs a course of varied length, 
possesses its virulence to the very end, and is in the highest degree 
contagious. 

Non-specific urethritis, as its name implies, differs from gonorrhoea in 
that it is not referable to a single cause. It is etiologically complex. 
Its causes arise from without and from within the urethra. Generally 
speaking, it comprises those cases of urethral inflammation not directly 
traceable to the gonococcus. It may resemble gonorrhoea so closely in 
all its symptoms that, clinically, a diagnosis between them often can- 
not by any possibility be made. This, however, is simply due to the 
fact that the symptoms of inflammation of the urethra, when they run 
high, are alike, whether their cause be specific or non-specific. Theo- 
retically, a distinction must be recognized between non-specific urethritis 
and gonorrhoea, although practically such a difference oftentimes cannot 
be demonstrated except by resort to the microscope. Clinically the 
symptoms of non-specific inflammation of the urethra have to be treated 
symptomatic ally in accordance with the grade of their intensity ; whereas 
gonorrhoea is treated with special regard for its specific cause. 

The intensely contagious quality of gonorrhoeal pus has been too long 
and too well known to require more than a mention. It has been demon- 
strated b}" direct experiment from urethra to urethra long before the dis- 



4 VENEREAL DISEASES. 

covery of the gonococcus. It was demonstrated witli equal certainty by 
oculists, by inoculation of the conjunctiva for clinical purposes. In the 
course of nature it is demonstrated upon the victim who has exposed 
himself to it in sexual intercourse ; and the eyes of a patient with gonor- 
rhoea may also attest the powerful contagiousness of this disease. 

No one can possibly dispute the fact that, if pus taken from a case of 
true gonorrhoea be placed upon the orifice of the urethra of the male, or 
the vagina of the female, an inflammatory disturbance of considerable 
intensity will be lighted up. But it was not until the discovery of the 
gonococcus by Neisser and its cultivation and reinoculation upon the 
human urethra by Bumm that the true etiological factor of this disease 
was disclosed. 

On the other hand, it is known that pus of the most varied character, 
not gonorrhoeal, but containing various forms of bacteria may be placed 
upon the meatus of the male urethra, or poured along its course, without 
inflaming the canal. In cases of intense balanitis beneath a very tight 
prepuce, the cavity of the foreskin is constantly filled with dense creamy 
pus ; yet in such a case, if the foreskin be slit up, it is often found that 
the glans penis is excoriated in patches, and the meatus of the urethra 
raw perhaps, but no urethritis exists. Pus from pyelitis may be voided 
as thick as cream through the urethra, but it does not occasion inflamma- 
tion of the canal. 

In the female, pus from the kidney or bladder, passing through the 
urethra, or pus in vast quantities coming from the uterus, may exert little 
more than a mild amount of mechanical irritation upon the parts over 
which it passes. 

Finally, the male often cohabits with a female whose vagina contains 
more or less pus from the uterus, and remains well ; while in many cases 
a mau with a more or less purulent discharge may lie with a woman, and 
she will remain sound. Not so in either case, however, if there be pres- 
ent the microbic poison of gonorrhoea. A gleet after gonorrhoea which is 
nearly well may give a gonorrhoea to a woman if the gonococcus be still 
present, as will a mild lurking inflammation in the vagina readily poison 
the male when its secretion harbors the presence of this specific organism. 

A large percentage of men in cities have a small amount of gleet from 
one cause or another; yet gonorrhoea in the females (their wives), with 
whom they cohabit, is not common — it is, indeed, exceptional. In France 
a gleet is considered a natural thing with a soldier, so much so that 
it is called the " military drop " ; but the women with whom they live are 
not necessarily affected with an analogous disorder. Indeed, there are 
certain forms of urethral discharge, which, the gonococcus having been 
carefully excluded, may call for the married state for their cure, and 
which get well during regular sexual hygiene, without involving the wife 
in any disorder. 



SPECIFIC AND NON-SPECIFIC URETHRITIS— GONORRHCEA. 5 

As to the power of pus in the vagina to give gonorrhoea to the male. 
Doubtless the male often gets his urethritis from contact with such irri- 
tating discharges, but he does not necessarily become irritated by them 
at all. Indeed, he usually escapes, unless his own urethra has been 
damaged by previous gonorrhoea, and he happens to be himself either 
debilitated, overtired, or full of liquor, or suffering coincidently from 
very acid urine, or unless he overstimulates himself sexually. All of 
these causes are capable alone of producing urethritis when the mucous 
membrane is in a morbid or congested condition, but are more apt to be 
predisposing in their nature, and the means of inducing acute inflamma- 
tion, through the activity of the various micro-organisms which commonly 
infest the urethra and vagina, and which, although not necessarily patho- 
genic, may become so under certain conditions. 

When a patient, however, offers himself, in sexual exposure, to the 
diplococcus of true gonorrhoea, he is almost certain to become poisoned 
without the co-operation of any of the adjuvants mentioned above. A 
simple exposure is enough. 

The theoretical distinction, therefore, between gonorrhoea and urethri- 
tis is clear; the clinical distinction is often equally so. Yet, without 
do^ibt, an intense urethritis is one and the same in its symptoms, whether 
its cause be the gonorrhoeal virus or any other microbic agent internal or 
external. 

From what has been written, it may be inferred that the causes of 
urethral inflammation are quite varied. The cause of true virulent 
gonorrhoea is single, namely, contact of the affected person with gonor- 
rhoea! pus from another person. Urethritis, however, may be produced 
in a variety of ways almost infinite, and it cannot be distinguished in 
its symptoms, when intense, from a gonorrhoea. This fact cannot be too 
often repeated. That surgeon is bold indeed, who, in the face of a cer- 
tain urethral discharge of given intensity, without the use of the micro- 
scope will pronounce upon its origin with any confidence, and some writers 
on account of the close resemblance in every particular of other 
micro-organisms to the gonococcus by microscopic examination, deem it 
necessary to resort to further bacteriological technique with the purpose of 
obtaining a pure culture in a suitable medium, before the question of its 
presence in a given discharge can be satisfactorily passed upon (see Bac- 
teriology of Urethritis). No one can be accused of impure relations be- 
cause he has a profuse urethral discharge. It cannot even be said that 
such a person has had sexual intercourse at all ; for it is possible for a man, 
virgin of all venery, to have an intense urethral inflammation, and much 
injustice may be done by accusing him, on the one hand, or, on the other, 
of accusing his partner — if he has had one — of having given him a dis- 
ease. 

The moral is, that the physician is not a judge. His function, if he 



6 VENEREAL DISEASES. 

has any of the judicial sort, is to shield the innocent. He should accuse 
no one, but confine himself to his own proper duties. 

If the urethra be healthy, it does not easily become inflamed, except- 
ing by contact with gonorrhoeal pus. Yet a healthy urethra does some- 
times suppurate after mechanical violence, such as the rough introduction 
of instruments through it; after chemical violence — the injection of irri- 
tating substances for experiment, or under the idea of employing a pro- 
phylactic against supposed infection. Under these circumstances the 
micro-organisms which are latent in the urethra exert a more or less 
virulent action against it as a result of the traumatism induced. A 
healthy urethra may also become inflamed by the combined influence of 
venereal excitement — especially if intense or prolonged — and contact of 
an irritating discharge, leucorrhoeal pus, menstrual blood, etc. Here the 
virulent factor is derived from without. 

An unhealthy urethra is always ripe and ready for inflammation. In 
strumous, strongly lymphatic, gouty, and rheumatic subjects, the urethra 
seems prone to take on inflammation easily, especially if the person be 
cachectic, overworked, or reduced in general health from any cause. In 
such cases all the mucous membranes are apt to be in an irritable condi- 
tion, and to take on subacute inflammation from trivial causes. 

When the urethra is actually diseased, on account of the previous 
existence in it of acute inflammation — when it contains a thickened, 
hypersemic patch, constitutiug a slight stricture — then it is in a prime 
condition to be irritated into suppuration — often a suppuration of formid- 
able proportions — by the action of those micro-organisms which, in the 
healthy urethra, fail to produce any apparent irritation. This is espe- 
cially true when the urethra, besides being the seat of a chronic patch of 
congestion left behind by an old gonorrhoea, is, at the same time, dia- 
thetically unhealthy, owing to the broken health, the bad hygienic 
surroundings, the cachectic condition, the nervous prostration, or the 
scrofulous or gouty constitution of the patient. 

When the mucous membrane of the urethra is unhealthy, the intro- 
duction of a sound will sometimes produce quite a sharp attack of ure- 
thritis. The passage of very acid urine through the canal may bring 
about the same result, whether the uric-acid crystals be due to indiges- 
tion, an attack of gout, or over-stimulation by alcohol (particularly beer 
or champagne). Mere excess of sexual excitement will sometimes pro- 
duce a flow of pus, and prolonged sexual intercourse may do the same, 
particularly if there be any purulent discharge in the vagina. In early 
married life the male is not unlikely to get a little urethritis from his 
wife; but after his approaches become less amorous, he has no further 
trouble. 

In connection with many morbid states of the prostate (cancerous, 
tuberculous, inflammatory) and of the urethra (herpetic, chancrous — 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 7 

tuberculous, syphilitic) a more or less purulent flow from the urethra may 
be encountered, and a purulent discharge attendant upon organic stricture 
is of every-day occurrence. 

Bacteriology of Urethritis. 

The various micro-organisms which normally inhabit the anterior 
urethra have been isolated and studied by different observers, notably 
Lustgarten and Mannaberg, Stein Schneider, Pettit, and Wassermann. The 
writings of these and other authorities furnish us with a knowledge of 
the bacterial flora of the normal urethra. An enumeration of the differ- 
ent forms would occupy unnecessary space. It is sufficient to state that 
these comprise bacilli of varying lengths and contour ; cocci variously 
grouped; diplococci, round, oval, and hemispherical; streptococci, small 
and large ; staphylococci, round and oval and of different sizes. There- 
fore when the gonococcus is implanted upon the urethra it is not inocu- 
lated upon a sterile territory, but one where already thrive myriads of 
different micro-organisms. How these latter modify the action of the 
gonococcus is hardly known, or what part they play in limiting its career 
in the urethra. That their presence is harmless in the quiescent state 
is beyond dispute, but that they assume under certain conditions very 
virulent properties seems to be proven in those forms of urethritis which 
come under the title of non-specific inflammation. 

It is now generally accepted that the gonococcus is the microbic agent 
of true gonorrhoea. It is also known that there exists a close analogy 
between some of the other diplococci and the specific organism of true 
gonorrhoea (the gonococcus of Neisser). In fact it is maintained by 
some that the so-called pseudo-gonococcus and the gonococcus of Neisser 
are indistinguishable in some instances, in which the former partakes 
of the characteristics of the latter without variation. Improvement in 
bacteriological technique, however, and the discovery of a reliable culture 
medium for the gonococcus make its differentiation a practical certainty, 
as it has been possible to reinoculate upon the human subject from a 
pure culture and demonstrate conclusively the specific action of the gonor- 
rhoea! organism. When the evidence furnished by means of the microscope 
and cover-glass preparations is negative, resort may be had to cultivation 
on a proper medium when absolute certainty of diagnosis is required. 
The advantage of cultivation is mainly in those cases in which a few shreds 
or filaments are present in the urine and nothing more, and in the case 
of patients who suffer from a very mild catarrhal gleet and who contem- 
plate matrimony. In either of this class of cases a positive diagnosis may 
be desired, but the gonococci, if present at all, are so scarce that the 
microscope may fail to find them until their number is greatly augmented 
by propagation upon a suitable medium. But when there are present in 



8 VENEREAL DISEASES. 

a given discharge suspicious organisms, which .^an be seen with the mi- 
croscope to resemble the gonococcus, differentiation can be satisfactorily 
made without cultivation, by means of the Gram method of staining 
(Plates III.-VII.). 

In cases of non-specific urethritis and pseudo-gonorrhoeal inflammation 
examination of the discharge reveals the presence of different kinds of 
bacteria, such forms as cocci and bacilli, which are known to be present 
in normal vaginal aud urethral secretions. That these organisms enter 
somewhat into the causative agency of non-specific inflammation there is 
no doubt, but in this particular they differ materially from the gonococ- 
cus, that their separation in pure culture and reinoculation do not result 
in the production of a similar inflammation, and therefore they may be 
said to be only one of the factors which enter into the causation of non- 
specific urethritis. 

Bockhart, ' in examining cases of catarrhal urethritis, found present in 
large numbers specimens of bacteria which inhabit the normal vaginal 
secretion. Bacilli were found only in small numbers. As the process of 
inflammation advanced, the number of organisms diminished so that 
finally one form only remained — a micrococcus. He found a coccus like 
the staphylococcus grouped as diplococci. These were smaller than the 
gonococci, the segments being hardly as large as the erysipelas cocci. 
No concavity in the segment was observed. They were isolated or jn 
clusters of great colonies. They were found within epithelial cells as 
well as within the protoplasm of the pus cells. 

Krause and Hirschberg, in examining several hundred ocular secre- 
tions, frequently found micro-organisms closely resembling the gonococcus 
Neisser, which were hard to differentiate from the latter. 

Elkhund found a similar form of diplococcus in the secretions of 
acute and chronic suppurative processes of the lungs and intestines and 
in ulcerous stomatitis. 

Bumm with Bockhart discovered organisms closely resembling the 
gonococcus in the genital tract of women. The former observer in ex- 
tensive investigations has made a study of the various organisms which 
closely resemble the gonococcus in the minutest detail. Some of these 
are pathogenic and others not. He enumerates several of the spurious 
forms and gives their bacteriological characteristics. The principal ones 
are: 1. A lemon-yellow diplococcus, non-pathogenic, found in the dust of 
the air, also in purulent secretions of the urethra and conjunctiva. 2. 
A milk-white diplococcus, non-pathogenic, found in the preputial smegma 
and in various secretions of the body and in ulcerous processes of the 
vagina and mouth. 3. A yellowish-white diplococcus, pathogenic, found 
in the lochial discharges, in the catarrhal urine of women after childbirth, 
also in mammary abscesses. 4. A gray -white diplococcus, non-pathogenic, 

1 Monatschrift fiir Derm., 1886, p. 134. 



KEYES AND CHETWOOD. 



PLATE I. 




1. Colony on nutrient agar of large dlplococcus from normal urethra. Magnified. 

2. Microscopical examination of same organism. 1,000 diameters. 

3. Pure culture on acid gelatin of Turro's diplococcus urethrJB. 1,000 diameters. 

4. Colony on nutrient agar plate of diplococcus found in catarrhal colpitis. Magnified. 

5. Microscopical examination of same organism. 1,000 diameters. 

CULTURES OF DIPLOCOCCI SOMETIMES MISTAKEN FOR THE GONOCOCCUS. (Heiman.) 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 9 

found in vaginal secretions. 5. A red diplococcus found in the dust of 
tlie air, non-pathogenic. Most of the above organisms are found to be 
readily cultivated at ordinary temperatures. 

It seems possible to cultivate them on gelatin and other ordinary 
media without difficulty, differentiating them from the gonococcus, which 
is difficult to cultivate and requires a special medium (Plates I. and II.). 

Neisser^ declares that urethritis can be caused by other bacteria than 
the gonococcus. He mentions a case in which no gonococci were found, 
but a large number of intra- and intercellular " bacilli diplococci " (" Stab- 
chen diplococci ") were present. 

The Gonococcus. — The gonococcus was discovered by Neisser in 1879 
in gonorrhoeal pus, and was first cultivated by Bumm in 1895. These 
organisms consist morphologically of micrococci, usually joined in pairs 
(diplococci) or in groups of four. The separate elements are flattened or 
hemispherical with the flattened surfaces approximated, and in the stained 
preparation presenting an unstained interspace. The approximated faces 
sometimes present a slight concavity. Their average size is 1.25 [j. in 
the long diameter. Their multiplication occurs by fission, alternately in 
two planes, as a result of which groups of four are frequently observed. 
The diplococci are more frequent. Single spherical individual cells are 
rarely seen. The microscopical appearances are not entirely characteristic 
of the gonococcus, as various other diplococci cannot be distinguished 
morphologically from the gonococcus. It readily stains with the basic 
aniline colors, especially with methyl violet, gentian violet, and fuchsin. 
It is negative to Gram's stain — that is to say, it is decolorized by the 
iodine solution used in this method. It has been stated that this char- 
acteristic does not serve to differentiate it, as other diplococci have been 
found in gonorrhoeal pus which react in the same way (Bumm); but 
it is held on equally good authority that the characteristic action of 
the Gram method upon the gonococcus is the best and most reliable 
means of establishing its identity, and that when confounded with other 
diplococci the error is due to faulty technique. In our judgment there 
is no better means than the Gram test for recognizing the gonococcus, 
but the greatest pains must be taken in every detail to make this test 
conclusive. 

Another distinguishing characteristic but of lesser diagnostic value is 
the fact that the diplococcus gonorrhoeae is found within the protoplasm of 
the pus cells. It is found also within the epithelial cells. Pus cells are 
observed entirely filled with these organisms. Bumm describes what he 
considers the one exception in a diplococcus found within pus cells from 
a case of puerperal cystitis. These cocci retained their color after being 
treated by the Gram method of staining. 

1 Deutsche med. Wochenschrift, 1893. 



10 VENEREAL DISEASES. 

To fix the identification, then, of the gonococcus there should be diplo- 
cocci of the right form, size, and arrangement. They must be negative 
to Gram staining, and should be observed within the protoplasm of the 
pus cells. The method of establishing the identity of the gonococcus 
by more elaborate bacteriological technique — namely, its cultivation upon 
a proper medium, also demands recourse to the Gram staining as a final 
means of identification. 

The gonococcus does not grow upon the ordinary cultivating media. 
It thrives best at the body temperature. The extreme degrees of temper- 
ature in which it grows are between 25° and 39° C. 

Various special media have been used successfully in the cultivation 
of this organism. Hammer^ describes a mixture of albuminous urine 
containing 1 to 1.5 per cent albumin with glycerin agar. The two con- 
stituents are separately sterilized and then mixed. Upon this medium 
the author obtained rich growths of the organism. 

Bumm first succeeded in cultivating the gonococcus upon human blood 
serum prepared from the placenta of a recently delivered woman. The 
other media used successfully have been prepared by mixing two parts 
of glycerin agar with one part of fluids rich in albumin, such as ascitic 
fluid, fluid from hydrothorax, hydrocele, or ovarian cysts. A more sim- 
ple plan is the use of the ordinary nutrient agar, the surface of which 
has been richly spread with human blood. The blood may be obtained 
directly from a small cut.'^ 

The gonococcus is a facultative anaerobe. Cultures upon the surface 
of blood serum are thin and scarcely visible. The surface is smooth, 
moist, and shining, yellow by reflected light; the edges of colonies are 
finely serrated. The growth spreads but slightly and does not continue 
more than two or three days, as the cocci lose their vitality. It is a 
strict parasite. (Sternberg.) 

Unless dried out, the gonococci may retain their vitality upon serum 
agar at the body temperature for four weeks. If dried they lose their 
vitality within a few hours. ^ 

The gonococcus has never been found outside of the body as a harm- 
less saprophyte. According to Heiman* the gonococcus remaining in the 
urethra after a gonorrhoea may lie dormant there and remain innocuous 
for years, and yet at any time excite an acute gonorrhoea in another per- 
son ; but this same author believes^ that the statements of Strauss, Pes- 
cioni, and Eraud, that the gonococcus occurs as a denizen of the normal 
urethra, are not satisfactorily proven by their published experiments. 

1 Deutsche med. Woch., 1895, p. 60. 

2 Abel: Deutsche med. Woch., 1893, p. 265. Fischer: Berliner klin. Woch., 
1895, p. 1156. 

3 Lehmann: "Bak. Diag.," 1896, p. 151. 

* Medical Record, December 19, 1896. ^lUd. 



KEYES AND CHETWOOD. 



PLATE II. 





. . .ft.* * . •% 









lir 



"""^i^^'. I 





3 

1. Colony on chest-serum agar of gonococci from male urethra. Magnified. 

2. Microscopical examination of a pure culture. 1,000 diameters. 

3. Gonorrhoeal pus sown on chest-serum agar, showing a pure gonoooccus culture. 



CULTURES OF THE GONOCOCCUS. (Heiman.) 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 11 

The various localities in which the gonococcus has been found comprise 
the urethra and prostate of man, the urethra, Bartholin's glands, and the 
cervix uteri of women. It has been found as the cause of vaginitis and 
urethritis of young girls. It has been discovered in endometritis, urethri- 
tis, salpingitis, oophoritis, peritonitis, proctitis ; probably also in epididy- 
mitis and cystitis J also in blennorrhoea neonatorum, conjunctivitis, 
rhinitis, otitis, and arthritis. It is still uncertain whether it occurs as 
the cause of pleuritis and malignant endocarditis. 

Flattened epithelial cells seem to serve as a better protection against 
infection than do columnar epithelia. 

This parasite has been observed to have penetrated the epithelium, and 
to have reached the connective tissue beneath. 

Immunity does not follow infection. 

Attempts to inoculate the lower animals are not successful and do not 
produce the true gonococcus of Neisser, but may yield a spurious organ- 
ism, somewhat resembling it morphologically, but which can be differ- 
entiated from it by means of the Gram test properly conducted. 

In order to demonstrate the presence of the gonococcus in cover-glass 
preparations we believe that the method of Gram should be relied upon 
entirely, and therefore a clear understanding of the various steps included 
in this staining method and differential test is absolutely necessary to 
success. 

In a valuable communication of his work in the library of the Paris 
Necker Hospital Dr. M. Weinrich, of Berlin, ^ lays great stress upon what 
he considers the most fruitful source of error in the conduct of this test, 
namely, the use of water for washing purposes in any of the steps. He 
believes that by so doing complete decoloration of the gonococcus, when 
washed in alcohol, is interfered with. 

What is known as Gram's solution consists of the following combina- 
tion : Iodine 1 part, iodide of potassium 2 parts, water 300 parts. This 
preparation is used in bacteriological technique for demonstrating the 
presence of various bacteria. The specimen is previously stained for one or 
two minutes by a solution of gentian or methyl violet, when it is treated by 
the Gram solution for the same length of time. This solution in the 
presence of the aniline dye forms an insoluble deposit which is confined 
to the bacteria, and which in the case of most bacteria is not dissolved 
out when treated with absolute alcohol until the specimen appears color- 
less to the naked eye. In treating the gonococcus of Neisser, however, 
in the same manner as above, it was discovered that the Gram stain is 
dissolved out of these organisms by the alcohol, while it remains fixed 
in any other organisms which may be present in the same field. Thus 
it may be seen that we have here a most valuable differential test for the 

' Annal. des Malad. des Organ. Genito-Urin., May, 1898. 



12 VENEREAL DISEASES. 

. gonococcus. As a final means of detecting gonococci, after they have 
been subjected to the various steps of the Gram process, it is necessary to 
submit them to a restaining by another aniline dye, preferably one which 
is markedly different in color from the original stain used in the Gram test. 
In the final microscopic examination of the dischargefrom a case of gon- 
orrhoea we have in the field a number of organisms which are not gono- 
cocci colored by the Gram stain, and in contrast to these the gonococci 
with the color of the second dye or counter-stain (Plates VI. and VII.). 

Thin smears of pus are first prepared on cover glasses and allowed to 
dry in the air spontaneously, or artificially by means of very gentle heat. 
The smear is then " fixed " by passing the cover glass three times through 
the flame of an alcohol lamp or Bunsen burner. The first step in the 
Gram method is to stain the smear with a solution of aniline dye. One 
of the best is that known as Ehrlich's solution, composed of a saturated 
alcoholic solution of gentian violet, 10 parts, in 90 parts of aniline water 
(Hogge). Aniline water is prepared by emulsifying 1 part of aniline oil 
in 20 parts of distilled water by shaking in a test tube. Allow the 
emulsion to stand a moment and filter through a wet filter until the fil- 
trate is perfectly clear. ]^ow cover the smear with the above aniline 
gentian-violet solution, and allow it to stain for one or two minutes. Do 
not wash with water, but remove the surplus dye by means of filter paper 
and transfer immediately to the Gram solution, where it should also re- 
main for one or two minutes. Next, again without washing with water, 
immerse in absolute alcohol until the color disappears and the preparation 
is perfectly clear to the naked eye. This should take from one minute to 
two minutes when the previous steps have been properly conducted. 
If water be used between the stages, or if the alcohol be not absolute, 
the process of decoloration will take much longer and the ultimate result 
may be unsuccessful. After this stage of decoloration by means of 
the absolute alcohol the gonococci will have lost their stain, while many 
other forms of cocci, such as staphylococci, which may be present in the 
pus, will still retain the dye (Plate V.). It now becomes necessary to 
counterstain the gonoccocci with some other color, and for this purpose we 
employ either Bismarck brown or Victoria blue. The Bismarck brown 
is prepared by adding 3 parts of the brown to 70 parts of distilled water 
and 30 parts of alcohol. The Victoria blue solution is made by adding 1 
part of the saturated alcoholic solution of this dye to 100 parts of water. 
The smear is treated with one of the above solutions for about three 
minutes, after which it may be washed with water. The specimen may 
also be washed with water after it has been decolorized with alcohol and 
before the counter- stain is used, the Gram process being then complete. 
Finally the preparation is dried, mounted in Canada balsam upon a slide 
with the smear turned downward, and examined with a J^-inch oil-im- 
mersion objective (Plates VI. and VII.). 



KEYES AND CHETWOOD. 



PLATE III. 




Specimen taken from case of Gonorrhoeal Urethritis, stained with gentian violet solution. 
Here the gonococci and pseudo-gonococci are stained alike and cannot be clearly differentiated. ii,000 
diameters. 



KEYES AND CHETWOOD. 



PLATE IV. 




Specimen from same case of Gonorrhoeal Urethritis as Plate III., treated by the Gram method, but 
before restalning. Here the gonococci which do not take the Gram stain are decolorized by the ab- 
solute alcohol, while the pseudo-forms, in marked contrast, retain the Gram color. 2,000 diameters. 



KEYES AND CHETWOOD. 



PLATE V. 




Specimen from same case of Gonorrhoea! Urethritis as Plate III., treated by the Gram method, 
and restained with Victoria blue. Here the gonococci take the color of .the secondary stain, while 
the pseudo-forms retain the Gram color. 2,000 diameters. 



KEYES AND CHETWOOD. 



PLATE VI. 




Specimen from the same case and treated in the same inanner as Plate V., but restained with Bis- 
marck brown. 3,000 diameters. 



KEYES AND CHETWOOD. 



PLATE YII. 




Specimen from case of Non-SpecifIc Urethritis, showing pseudo-gonococci stained with gentian 
violet. 2,()00 diameters. 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. IB 

Fraenkel, of Hamburg, ^ has suggested the substitution of carbolated 
for aniline water in the preparation of Ehrlich' s solution and in the same 
proportion, that is to say, 10 parts of saturated alcoholic solution of 
gentian violet to 90 parts of two-per-cent carbolated water, and this 
author has found that the above solution resists decomposition for a 
much longer period than the aniline-water preparation, and on this ac- 
count it is certainly to be recommended as a desirable substitute, for any 
decomposition in the aniline gentian-violet solution is liable to lead to 
errors in the microscopical examination, in view of which possibility it has 
been recommended that the aniline solution be made fresh before each 
examination. By using the carbolated solution this precaution becomes 
unnecessary. 

To recapitulate, the steps in staining cover-glass preparations in ex- 
amining for the gonococcus are : First spread a very jfine film of dis- 
charge upon a cover glass. Allow this to dry spontaneously or by gentle 
heat. " Fix ^' by passing the cover glass three times through the flame 
of an alcohol or Bun sen burner. Stain with gentian- violet solution, pre- 
ferably that made with carbolated water, for a period of one or two minutes. 
Remove the surplus solution with filter paper, but do not wash with 
water. Next immerse in the Gram solution for a similar period. De- 
colorize with absolute alcohol until the specimen is clear to the naked 
eye. This should take about one minute and a half. Now wash in 
water [the Gram test being completed] to remove the alcohol and restain 
with a solution of Bismarck brown or Victoria blue. Wash again in 
water, dry the cover glass, and mount with Canada balsam. Examine 
with J^-inch oil-immersion objective. 

In keeping with the careful observations of Nogues, Weinrich, and 
others, we must emphasize the most important precaution in the conduct 
of this process to insure a successful result — namely, the use of absolute 
alcohol for the purpose of decoloration and the avoidance of the use of 
water between the various steps, until after decolorization shall have 
been effected. 

Symptoms of Urethritis. 

In studying the symptoms of inflammation of the urethra, it will be 
convenient and practical to make two classes of cases, according to the in- 
tensity of the inflammation, and briefly to review the symptoms in each. , 

Symptoms of Simple Non-Specific Urethritis. — This is by far the com- 
monest form of urethritis. This is likely to be the form which those have 
who boast of a dozen or more attacks of gonorrhoea, and of those indi- 
viduals who claim they get the gonorrhoea constantly, but do not mind 
it, as they have a little, injection which cures it up in three or four 

1 Deutsche ined. Wochenschrift, 1885. 



14 VENEREAL, DISEASES. 

days. In this form the patient gives himself the disease much more than 
his partner gives it to him. He has a damaged patch of mucous mem- 
brane within his urethra, and any one of a number of exciting causes is 
sufficient to kindle the slumbering congestion into an active discharging 
inflammation with the aid of those micro-organisms which constantly in- 
habit the urethra and vagina, and under normal conditions remain there 
as harmless saprophytes. 

In these cases the discharge may originate at a certain distance within 
the urethra from the very start. It may not commence at the meatus. 
The patient has intercourse perhaps with a woman who has no gonor- 
rhoea — who at most has a purulent leucorrhoea. In twenty -four to forty- 
eight hours he presents himself to the physician for inspection, stating 
that he has an attack of gonorrhoea. 

When inspection shows that the lips of the meatus urinarius are not 
swollen, the attack has manifestly not begun at the meatus. When, how- 
ever, the cause is some irritating discharge from without, not gonor- 
rhoeal, commonly the evidences of commencing irritation appear at the 
meatus. The discharge may be thick and purulent from its very start. 
There may be little or no itching, or tingling, along the course of the 
urethra. There is some heat and smarting in the urethra during the 
urinary act, but very little discomfort between times. 

A discharge starting in this way is not apt to be a true gonorrhoea; 
but it may go on and assume all the quality of the most intense gonor- 
rhoea! urethritis, accompanied by any of the complications of gonorrhoea, 
and absolutely indistinguishable from it clinically; or it may subside 
in a few days, or, at most, weeks, under moderate symptomatic treat- 
ment, and give very little discomfort. The latter termination is by far 
the more common. 

Symptoms of Specific and Intense Non-Specific Urethritis. — Specific 
urethritis always commences at the meatus, inoculation with gonorrhceal 
pus is the cause, and there is always a period of incubation between the 
moment of exposure and the outbreak of the first symptom. This incu- 
bation period is usually from five to eight days, and sometimes much 
longer. When, however, the cause is not gonorrhoea!, the evidences of 
irritation appear almost simultaneously with the cause or on the second 
day following; sometimes they are delayed up to the fourth or even 
sixth day, but rarely any longer. 

The first symptom in these cases is an oedema of the meatus, which 
makes the lips of the urethral orifice pout. This swelling may be insig- 
nificant in non-specific urethritis; it is invariable in gonorrhoea. The 
color of the orifice of the urethra is pink rather than blue. The patient 
feels a sensation as though a hair had been caught in the meatus and was 
being drawn through it. There is a sensation, varying between a tick- 
ling and an itching, which is quite apt to be complained of, either at the 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 15 

very meatus or at a point about three-quarters of an inch within the 
urethra, upon its under side. These sensations keep the patient's mind 
fixed upon his genitals, and call upon him to empty his bladder rather 
more frequently than usual. The passage of urine over the tender ends 
of the urethra causes a hot, stinging pain, an ardor urince, more or less 
intense, in different patients. 

Between the lips of the pouting meatus, perhaps faintly sealed with 
dried mucus, a drop of watery pus is seen during the first twenty-four 
hours. On the second day this drop becomes more purulent, and all the 
disagreeable sensations increase, while from day to day the discharge be- 
comes more copious and more purulent, except when under the influence 
of restraining treatment. 

During the second week the pus from the urethra assumes a green 
t?nt, due to slight admixture with blood, and all the symptoms intensify, 
unless the discharge turns out to be a mild urethritis, in which case it 
sometimes reaches its height during the first week, and commences to 
decline during the second. This it never does if it is true gonorrhoea, 
and is allowed to run unchecked. 

If the inflammation runs high at any period of the disease, erections 
become painful ; the inflammation does not remain confined to the surface 
of the urethral membrane, but works down through the minute ducts into 
the mucous glands of the urethra, and spreads from thence to the delicate 
meshes of the spongy tissue of which the corpus spongiosum is composed. 
These meshes of tissue, becoming stiffened and agglutinated together by 
the inflammatory process over a given (usually limited) area, no longer 
allow themselves to become distended by the influx of blood which occurs 
during erection. As a consequence, when the rest of the penis is dis-' 
tended with blood, and only a limited portion remains empty, the empty 
part, being relatively too short, draws together the distended parts, act- 
ing like a cord to a bow, and the penis becomes curved, its point of 
greatest concavity corresponding to the inflamed area of the corpus 
spongiosum. The inflammation often does not ran so high as to obliter- 
ate the meshes of the corpus spongiosum, but renders them sensitive 
when dragged upon. In such a case there will be a painful, perhaps 
hard spot in the urethra upon erection, but no bending of the penis. 

This bending of the penis is called chordee. Painful erections are 
not uncommon during the third week of a gonorrhoea, and may continue 
until the discharge has ceased. These intense symptoms, notable in 
gonorrhoea, are dependent upon the pathogenic action of the gonococcus 
upon the tissues. This microbic agent is first implanted upon the epi- 
thelium of the meatus, where it rapidly proliferates and thence penetrates 
gradually between the cells into the subepithelial tissue. Here a high 
degree of irritation is set up around the blood-vessels, and all the phe- 
nomena of inflammation ensue. This entails desquamation, serous exu- 



16 VENEREAL. DISEASES. 

dation, migration of large numbers of white blood corpuscles, and general 
round-cell infiltration. 

The intensity of the inflammation, and hence the symptoms produced, 
vary according to the number of gonococci, the rapidity with which they 
proliferate, and the susceptibility of the tissues. 

During the second or third week, as the inflammation extends back- 
ward within the canal of the urethra, the deep urethral muscles are apt 
to be thrown into spasm, which leads to dribbling of urine and difficulty 
in voiding the contents of the bladder. Sometimes actual retention 
comes on, usually only in connection with active inflammatory congestion 
of the prostate and cystitis of the neck of the bladder. Abscess of the 
prostate, peri-urethral abscess, perineal suppuration, inguinal glandular 
abscess, and swelled testicle are among the complications of intense in- 
flammation of the urethra. Inflammatory complications of the fundus of 
the bladder and of the kidneys occur, but are rare in connection with 
gonorrhoea unless neglected' or ill-treated. 

In some cases the prepuce becomes implicated in inflammation. This 
is due to a lymphangitis, generally of the smaller lymphatic vessels. 
As a result the foreskin may swell enormously, and become white with 
oedema, and this oedema may go on to involve the whole penis. It fre- 
quently leads to paraphimosis, when the prepuce is short. If the pre- 
puce be long, phimosis is apt to occur, and occasionally the inflammation 
runs on to the extent of producing abscess between the layers of the 
prepuce. 

When the prepuce is tight, although it may not become inflamed in 
its own texture, yet if the discharge is not kept carefully washed out 
of its cavity, the pus is liable to be retained in the furrow behind the 
glans penis, and there becoming decomposed, to give rise to balanitis and 
posthitis, and to lead to the formation of innumerable warts, the so- 
called venereal warts, which are always likely to be produced bj unclean- 
ness beneath the prepuce. The above evidences of extension of inflam- 
mation beyond and exterior to the mucous membrane are caused not by 
the gonococcus but by the ordinary pyogenic micro-organisms. 

When the urethral inflammation runs high, hemorrhage from the 
urethra may occur, either spontaneously during erection or as a result of 
straightening the curved penis during erection. When the penis is so 
straightened the inflamed spot of corpus spongiosum may be ruptured 
through the mucous membrane of the urethra, and violent hemorrhage 
may follow, to say nothing of the traumatic stricture which is sure to 
appear subsequently at the point of rupture. 

In those rare cases in which upward chordee appears on account of 
inflammation of the corpus cavernosum, violent straightening may cause 
effusion of blood within the sheaths of the corpora cavernosa, but rarely 
produces free bleeding from the urethral surface. 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 17 

After the urethral flow has continued at its height for a period varying 
from one week to a number of weeks, the inflammatory symptoms gradually 
subside, chordee becomes less frequent and less intense at night, the dis- 
charge lessens, and finally ceases entirely. It may relapse, leading to a 
new discharge lasting for several weeks, or prolong itself indefinitely in 
the shape of a gleet, which is more or less puriform in different cases, 
and subject to exacerbation and improvement, from time to time, from 
varied trivial causes. 

Diagnosis, Dukation, and Treatment. 

Before deciding upon the proper course of treatment in a given case 
of urethritis, the determination of the cause upon which it depends is a 
necessary preliminary step. 

In the light of our present knowledge regarding the causative agency 
of the gonococcus in cases of specific urethritis, it is hardly necessary to 
state that it is always proper to resort to the means already dwelt upon 
to determine the question of its presence in a purulent discharge from the 
urethra. 

The treatment of a mild case of non-specific urethritis often resolves 
itself into a simple removal of the cause underlying it. 

The treatment of specific urethritis and of the more intense form of 
non-specific urethritis requires a resort to active local and antiseptic 
measures, to be hereinafter described. It is often possible to reach a fair 
presumption regarding the character of a case of urethritis by plying the 
patient with such questions as will bring to light the period of incubation, 
if any, the intensity of the symptoms, the number and duration of pre- 
vious attacks, and by taking account of the apparent health and habits 
of the individual. A patient who has had a number of previous attacks 
of mild urethritis, which have always yielded to simple measures, is apt 
to treat the whole question of gonorrhoea with small concern and to en- 
deavor to impress his views upon his less experienced brethren. Such a 
man has rarely had more than one case of true gonorrhoea, the successive 
outbreaks being relapses of the original malady, or the result of morbid 
conditions, local or constitutional, which render him susceptible to irri- 
tating influences which do not act upon the normal urethra. A first 
attack of acute urethral inflammation, following a suspicious intercourse, 
is always strongly suggestive, on its face, of specific urethritis. 

The patient who comes with his virginal attack of gonorrhoea is 
generally totally ignorant of the virulent nature of his disease, and de- 
luded by the information of his friends. He should be informed that 
gonorrhoea, badly managed, is as serious a matter, in many cases, as 
syphilis; that gonorrhoea probably kills more patients than syphilis does, 
through its ultimate effect, by means of stricture of the urethra, upon 
2 



18 VENEREAL DISEASES. 

the bladder and the kidneys. The surgeon should refuse in any case to 
give a promise of cure in any specific time. No man can positively assert 
at the start whether a given urethral inflammation just commencing at the 
pouting orifice of a healthy urethra is to be a severe case or not, or whether 
it will yield a prompt response to remedies. While it is possible to settle 
at once the question of specificity by microscopic examination, it must 
not be forgotten that some cases of so-called non-specific urethritis have 
all the intensity of gonorrhoeal inflammation and may run a prolonged 
course. 

If a man has already had several attacks of gonorrhoea, and his pres- 
ent attack comes on without any oedematous swelling of the meatus 
urinarius, the chances are that the attack will be a mild one. If the 
case is one of first attack, and there has been not more than forty-eight 
hours ^ incubation, the chances also are that the inflammation will not be 
violent. If there has been no sexual intercourse at all to occasion the 
new outbreak, the course of the malady may be slow and its duration 
protracted, the symptoms may or may not run high. 

Diagnosis. — The diagnosis of acute urethritis is generally easy, and de- 
pends upon the presence of a purulent discharge from the urethra with the 
attendant symptoms of inflammation. It must be distinguished from a 
balano-posthitis when the discharge collects between the glans and the 
prepuce and exudes from a phimosed opening. 

The hypersecretion of the glands of the urethra and the prostate is 
of a non-purulent character, and thus is recognized. Sometimes the pres- 
ence of a chancre within the urethra will cause a discharge from the 
meatus and mislead the surgeon, but a short lapse of time will generally 
bring to light the real cause. Having excluded the above sources of pos- 
sible error, the diagnosis lies between specific and non-specific urethritis, 
which is determined by bacteriological examination. 

Finally, when the gouococcus is sought for and not found, and the 
case appears to be one of a succession of similar attacks which have 
occurred at various intervals, structural changes in the urethra or morbid 
conditions of its adnexa are generally responsible for such acute outbreaks, 
and must be located by appropriate methods when the acute stage subsides. 

Duration. — The duration of non-specific urethritis, when the exciting 
cause is derived from alcoholic excess or other means of local irritation, 
is generally short and readily controlled by the removal of such cause. 

When the acute inflammation springs from a urethra already the seat 
of structural changes, the result of previous trouble, it will often subside 
in a short period under mild treatment, only to blossom out again later 
when sufficient cause recurs. 

Urethritis occurring in rheumatic, tuberculous, and cachectic subjects 
is more apt to assume a severe form, and to extend over a prolonged period. 

Severe non-specific urethritis and its prototype, true gonorrhoea, vary 



SPECIFIC AND NON-SPECIFIC URETHRITIS— GONORRHCEA. 19 

in the length of their duration according to the intensity of the inflam- 
mation, the treatment employed, and the time at which treatment is 
commenced. 

Formerly, under the rational measures of treatment then in vogue, a 
period of six or eight weeks was considered an average duration, and in 
severe cases longer periods were not considered excessive. At the pres- 
ent day claims are made of effecting a cure in as short a period as one 
week, and even less. In spite of this, however, two weeks must still be 
considered a short period of treatment, three weeks a reasonable dura- 
tion, and four weeks not excessive. 

To obtain these rapid results the patient must be seen early in the 
career of his disease, and the treatment continued in a most careful but 
energetic manner. It is more creditable to the surgeon to conduct a case 
through the course of the disease free from complications than to shorten 
its duration by one or two weeks. 

Treatment. — The general treatment of all cases of urethritis should 
aim at an intelligent observation of the symptoms, and, according to the 
nature and intensity of a given case, the adoption of measures hygienic, 
medicinal, and antiseptic. 

In all cases of gonorrhoeal and severe cases of non-specific urethritis 
hygienic measures and absolute regularity of life should be enjoined from 
the start; anything like irregularity is detrimental. The patient should 
rest as much as possible, lying down rather than sitting or walking. He 
should avoid exercise and fatigue. In severe cases absolute confinement 
may shorten the period of the disease and render it more tractable to 
treatment. Regularity should be practised in sleeping and in eating, and 
particular attention should be bestowed upon the function of the intestine. 

The amount of food taken should be moderate, its quality bland and 
unstimulating, its nature light and varied. If the patient be debilitated, 
on the other hand, plenty of meat should be allowed, the full ordinary 
amount of food should be taken, and in some cases even a little red wine, 
diluted with water, from the very beginning. Milk is an excellent article 
of diet in all cases. When it cannot be promptly digested, the work of 
the stomach may be made easier by adding salt to the milk; and a laxa- 
tive, such as a dinner-pill, may be given at night, or a little compound 
licorice powder, or, if the patient prefers, a saline aperient water in the 
morning. 

Among the articles of food to be avoided in all acute cases (excepting 
those coming on in decidedly debilitated subjects, when intelligent ex- 
ceptions must be made), are pastry, gravies, fried fats, and greasy articles 
of food, all rich made-dishes and indigestible substances, all condiments 
of every description, excepting in the mildest form. Salt, however, is 
not objectionable; pickles and acids usually are. Asparagus is harmful 
to some patients. 



20 VENEREAL DISEASES. 

Among the drinks to be avoided are strong coffee and teaj all wines 
and liquors of any description, particularly the fermented wines and malt 
liquors. 

Soda water, root beer, and Yichy water may be used as beverages, 
and the more water that can be taken between meals the better, particu- 
larly one of the diluent mineral waters which pass rapidly through the 
kidneys. It is always well for patients to take a full glass of water upon 
retiring, so that the morning urine may be less dense than would other- 
wise be the case. 

Smoking is not objectionable. 

Everything which tends to sexual excitement, whether by thoughts, 
conversation, or actions, should be interdicted. The penis should be 
handled as little as possible. 

This latter precaution must be strictly enforced for two reasons. In 
the first place, the constant pulling at the urethra, in order to see how 
much pus it contains and what its quality may be, is irritating to the 
inflamed mucous membrane of the canal. In the second place, fingering 
the urethra exposes the eyes of the patient to inadvertent inoculation. 
The caution of extreme cleanliness and avoidance of the contact of any 
pus from the urethra with the conjunctiva should be very forcibly given 
to each patient, and frequently repeated and insisted upon. 

As a final hygienic precaution it is well for the patient to carry his 
testicles in a suspensory bandage, since the tendency to epididymitis is 
in this way decidedly lessened. 

All the hygienic precautions alluded to should be held in force during 
the whole course of ' an urethral discharge, and for a certain period after 
its apparent cessation (a week to ten days), through fear of a relapse. 
But all the foregoing restrictions may be more or less relaxed in mild 
non-specific cases of urethritis. 

Internal Treatment. — This comprises the use of : 

Alkalies and diuretics, to render the urine bland and unirritating. 

Balsams, santal oil, etc., which act favorably upon the mucous mem- 
brane of the urethral tract in passing out of the system. 

Sedatives and anodynes, to lessen ardor urinse when intense, and con- 
trol chordee. 

Internal antiseptics are sometimes used for their bactericidal action. 
For this purpose salol, fifty to sixty grains daily, or methylene blue, two 
grains three times a day, have been given but possess no established 
value. 

The first thing to be done in severe, notably gonorrhoeal cases is to 
see that the urine be made abundant and alkaline, so that it may be 
bland and unirritating in its passage over the inflamed surface of the ure- 
thral mucous membrane. To accomplish this dilution of the urine it may 
be enough to take an extra tumbler of water several times a day between 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 21 

meals. Should the dilution of the urine not materially reduce its acidity, 
some alkaline drug may be given well diluted with water, and adminis- 
tered during the third hour after each meal. 

The best alkaline drug, in cases of irritation of the bladder or urethra, 
is the citrate of potash. This salt, however, is unstable, and should 
always be obtained from a reliable pharmacist. In solution, after being 
kept for a time, it becomes changed to the carbonate of potash. The 
carbonate of potash, although a fair alkali, is not so good a diuretic as 
the citrate, and does not, as a rule, agree as well with the stomach. 

The citrate of potash may be given in doses of five, ten, or fifteen 
grains three times a day, according to the effect upon the urine. Occa- 
sionally it disagrees with the stomach, even when taken in small amount. 
Under such circumstances it produces a sense of discomfort in the region 
of the stomach, perhaps nausea, possibly diarrhoea, and sometimes a 
pain in the head across the forehead. In these cases the remedy must 
be discontinued, and some other alkali tried. Vichy water and soda 
mint tablets may answer all purposes, one or two of the latter to be taken 
with each glass of vichy, several times daily. 

If the case be one in which there is reason to suspect that the discharge 
comes from a patch of damaged urethra, strictured or not, which has been 
excited to suppuration — where, for instance, a drop of pus appears at the 
beginning of the attack in a meatus which is not oedematous or swollen, 
in such a case there is sometimes no occasion for any further internal 
medication than the alkaline diuretics already alluded to. A very mild 
injection may be used at once, increased in strength every few days; and 
very often in a short time the supposed gonorrhoea subsides, and the 
patient rejoices in an escape from a prolonged sickness which he had 
perhaps looked upon as inevitable. 

Of all the mternal remedies in vogue there is none more generally 
efficacious than the yellow oil of sandal-wood. This may be given in 
pearls or capsules, ten, fifteen, or twenty minims three times a day. 

Sometimes it may be desirable to give the oil and the alkali combined 
in a single prescription, such as the following, which is not unpalatable : 



"^ 01. santali, 

Liq. potassse, ..... 

Syr. acacise, 

Aquse foeniculi, 

M. S. Teaspoonful, well diluted, after eating 



. § ss.-i. 
. 3 ij.-iv. 

q.s. ad 1 iij. 



The oil of gaultheria may be substituted for the sandal-wood in the 
above prescription in the same proportion, sometimes with good effect. 
It may be administered alone in capsules. In like manner the oil of 
eucalyptus may be preferred, according to individual peculiarities in a 
given case. 

Sandal oil agrees with most stomachs much better than copaiba. It 



22 



VENEREAL DISEASES. 



produces no trouble upon the skin, and is not apt to excite diarrhoea. 
When it disagrees, it generally does so by causing intense pain in the 
back, over the region of the kidneys. In pushing the drug to obtain its 
full effect, it is well to increase the dose until some uneasiness is com- 
plained of in this region, and then to reduce it for a day or more, waiting 
for the pain to subside, as it does quite promptly. After this the drug 
may be resumed at an appropriate dose. 

The effect of sandal oil in full doses is usually soothing to the patient's 
sensations. In cases of ordinary urethritis it often promptly modifies the 
intensity of the discharge. In true gonorrhoea it is less effective, and 
may exert no influence whatsoever without the use of local measures. 

The balsam of copaiba is a time-honored remedy for urethral inflam- 
mation, is inexpensive and therefore generally quite pure, no matter 
where obtained. Copaiba is often a very useful drug in the treatment of 
urethritis, but it is nowadays less often employed when much reliance 
is placed upon the local measures. In these cases, when it is impossible 
or inexpedient to use local means, its use in one of the various combina- 
tions may prove of decided value. In non-specific urethritis it may be 
used at any period, but in true gonorrhoeal urethritis it is more suitable 
for the later stages. Indeed in some instances the symptoms of gonorrhoea 
are rendered more intense by the too free use of balsams (copaiba or 
cubebs) in the early stage. The balsam may be given in combination 
with an alkali, in a prescription similar to the one already advised for 
sandal-wood oil, or in one of the following mixtures : 



I^ Bals. copaibse, 

Liq. potassse, 

Syr. tolu, 

Extr. glycyrrhizse, 

Aquse menth. pip., q.s. ad 

M. Shake. S. One to two teaspoonfuls at a dose. 



I^ Bals. copaibse, 

Syr. tolu, 

Syr. acacise, 

Aquae mentli. pip. , 
M. Shake. S. Teaspoonful t.i.d. 



2 ss.-i. 

3 ij.-iv. 
§iss. 
3ij. 
!iij. 



3iv. 



aa 3 viss. 



The balsam may be administered in an endless variety of combina- 
tions, mixed with sandal oil, with cubebs, and in countless mixtures 
which are prepared by different drug houses from the favorite prescrip- 
tions of various physicians. In general, the method by tablets or cap- 
sules is most convenient and palatable, since the drug is tasted only 
during the regurgitations in the throat, which are so constant and offen- 
sive in some people when they take copaiba. The odor of the balsam 
also remains on the breath, and is quite strong in the urine of the patient 
in all cases. 



SPECIFIC AND NON-SPECIFIC URETHRITIS— GONORRHGEA. 23 

Copaiba disagrees with many patients. It causes acute indigestion 
in somC;^ and more moderate dyspepsia in others. Sometimes it will not 
stay down at all, but is rejected by the stomach. Occasionally it pro- 
duces headache and great depression of spirits. Sometimes it causes- 
diarrhoea. The urine, when full of copaiba, may coagulate under heat in 
a manner suggestive of the presence of albumin. 

One of the specific effects of copaiba is to produce an acute eruptive 
disorder, known as copaibal roseola or erythema. Its advent is frequently 
announced by a chill, with headache and nausea, sometimes by diarrhoea 
and considerable fever. The eruption is general, and consists of red 
raised blotches which itch intensely. 

When the eruption appears, the urethral discharge becomes greatly 
modified, or ceases entirely, but it generally returns as the eruption 
fades. 

The treatment of copaibal erythema is to give plenty of fluids by the 
mouth, and bland diuretics, to assist the kidneys in eliminating the 
offending substance from the blood. Warm baths are comforting, espe- 
cially if they contain a little baking-soda — about one ounce to thirty gal- 
lons — or some of the infusion of bran, as in the ordinary bran-bath. 
Dusting the skin with starch-powder is cooling, and a few days generally 
suffices so to moderate the eruption that the itching is no longer distress- 
ing. On the first appearance of this eruption the copaiba must be 
stopped ; but it may be resumed again, if it be desired, in smaller doses, 
after the eruption is well on the decline. 

Cubebs is another remedy which has stood the test of time ; it may 
be administered as a powder, or in drachm-doses of the fluid extract. 
The oleoresin is a very useful preparation, notably in the subacute and 
chronic cases and in the declining stage of acute urethritis; not in the 
early stage. The dose is from ten to thirty minims, and it may be ad- 
ministered in various ways. Small quantities are easily taken upon a 
lump of sugar, larger doses best in capsules. One capsule at a dose is 
enough to begin with, to be gradually increased. Patients generally halt 
at three capsules at a dose, but sometimes they take four. 

The effect of cubebs in moderate doses is rather to stimulate digestion 
and act as a tonic. The breath smells of it, and the urine is full of its 
odor. Large doses are distinctly irritating to the stomachs of most 
patients, and cause diarrhoea, with griping pain. If the neck of the 
bladder happens to be at all congested, or if the organ tends to be irri- 
table, cubebs is generally harmful, since it aggravates such conditions, 
and, if pushed, may go so far as to bring on inflammation of the neck of 
the bladder. If the local antiseptic treatment of gonorrhoeal urethritis is 
objected to and an antiphlogistic regime is preferred, the proper manner 
of adopting such a course is to hold to the use of alkalies and diluents 
until the acute symptoms subside, and then to resort to the use of cubebs 



24 



VENEREAL DISEASES. 



Copaibse, 


TTl V. 


Copaibae, 


mil]- 


Salol., 


gr. iiss 


01. santal. 


, TTIV. 


01. resin, cubeb., 


miij. 


01. santal., 


Tilv. 






01. resin, matico, 


mi. 


Pepsin. , 


gr. i. 






01. santal., 


miij. 







and copaiba during tlie last stage. Guiard of Paris commends this course 
in all cases. 

Turpentine is sometimes distinctly useful in the declining stage, and 
in subacute or chronic cases of urethritis ; it may also be given in those 
cases in which cubebs does not agree. The oil of turpentine may be 
taken upon a lump of sugar, in five- to twenty-drop doses, three or four 
times a day. If preferred, it may be given very conveniently in the 
form of the pearls of turpentine (fil v.), as they are called, prepared by 
various manufacturers. The dose of these is from one to three. 

Sometimes turpentine acts as an irritant, just as cubebs does, and 
^induces frequent urination. In such case, the remedy must be changed 
or the dose lessened. The tincture of cantharides has somewhat the 
same range of action as turpentine, but should be still more exclusively 
confined in its use to the subacute and chronic stages. It is given in 
TTt iii.-vi. doses three times daily, well diluted. 

One. of the following combinations of the above preparations, which 
are put up in capsules by different chemists, may be chosen according to 
the lights of the physician and the peculiarities of different cases : 

Copaibge, tti, vi. 

Cubeb. ol. resin., Tix ij. 
01. santal., m ij- 

The oil of sandal-wood and salol are suitable to all stages of acute 
urethritis, but the other combinations to the subacute and chronic cases 
and to the later stages of acute urethritis. 

When chordee and ardor urinse become severe in spite of the use of 
alkalies and diluents, it is necessary to employ additional remedies to con- 
trol these symptoms. Sometimes the addition of a small amount of 
codeine, gr. ^ - ^ three times a day, may be sufficient to palliate them. 
This may be given in a tablet triturate or added to the liquid" mixture. 
A large dose of codeine (gr. ii.), given at night, may prevent chordee. 
Phenacetin (gr. v. or x.), lupulin (gr. xxx.-lx.), and bromide of potas- 
sium (gr. Ix.-xc.) are sometimes taken for the same purpose before re- 
tiring. The objection to lupulin is that it is very bulky, and to the 
bromide that it upsets the stomach in such full doses. 

The tincture of hyoscyamus is an excellent remedy for controlling the 
ardor urinae. It may be administered in one of the mixtures already 
mentioned : 

I^ CodeinsB [spts..rect. q.s. ad sol.], . . . . gr. iij.-vi. 

01. santali (or gaultheria, or eucalyptus), . . . ^ ss. 

Tinct. hyoscyami, 3 iss. 

Liq. potassse, . . . . . . . .31]. 

Syr. acacise, q.s. ad ^ iij. 

M. S. Teaspoonful three times a day. 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 25 

In this mixture the codeine need not be included unless needed. The 
oil may also be removed and given instead in capsule form. 

Finally, some cases of non-specific urethritis, which occur as a result 
of an oversensitive state of the urethra, accompanying diathetic condi- 
tions, anaemia, and malnutrition, require such internal remedies as will 
directly benefit the underlying condition. Iron and arsenic as general 
tonics, cod-liver oil and creosote for some cases, will at times, in addition 
to the local or internal treatment already instituted, be the means of 
bringing about a favorable result. 

Before proceeding to the consideration of the local treatment of acute 
urethritis, attention should be called to the fact that there are two 
methods in vogue of treating this malady, either one of which may result 
in a safe and complete cure, but with a decided difference in the period 
of duration. 

The antiphlogistic method recommended particularly by Fournier and 
Guiard of Paris, and others, disapproves of the employment of any local 
measures in the early stage when the acute symptoms run high, but relies 
upon the free use of alkaline diuretics and diluents during this period, 
which is intended to permit the discharge to flow freely without restric- 
tion, and only when the discharge has materially decreased and the acute 
stage has subsided are local measures adopted. The latter consist of 
astringent injections in some form or of irrigations. 

The alternative course, and the one recommended in this book, consists 
in the adoption of local measures at the onset of the inflammation, for 
the purpose of destroying or restraining the microbic agents and curtail- 
ing the attack of the disease. 

Local Tbeatment. 

The local measures adopted in the treatment of urethritis should vary 
according to the nature and intensity of the inflammation. 

The judicious use of local applications in specific urethritis is the 
most important feature in the treatment of this malady when, the pres- 
ence of the gonococcus having been established, it is desired to cut as 
short as possible the stay of this micro-organism in the urethra. 

In casQS of non-specific urethritis, intense and active, local measures 
play an important role in the treatment; while in mild non-specific 
cases, and those which depend upon diathetic and constitutional causes, 
such means are often unnecessary, and may even be the cause of prolong- 
ing the symptoms. 

The different therapeutic agents adopted for urethral medication are 
intended to exert germicidal, astringent, or stimulating effects, as the 
case may require, and are employed by means of copious irrigations, 
instillations or injections, and in soluble bougies. 



26 



VENEREAL DISEASES. 




The Abortive Treatment of Gonorrhoea. — It is generally conceded 
that an abortive treatment of gonorrhoea, to be successful, must be 
resorted to within a few hours after the first appearance of the urethral 
discharge. While many of the local antiseptics, commonly employed at 
the present time, have the effect of shortening the course of a gonorrhoea, 
they cannot strictly be considered as abortive measures. A treatment 
which is deserving of this title must quash the disease at its onset and 
prevent its evolution. For this purpose the permanganate of potassium 
has been employed in strong solutions (1 : 500 and 1 ; 1,000) by copious 
irrigations of the anterior urethra a few hours after the discharge appears ; 
also the nitrate of silver (2-4 per cent solution) and corrosive sublimate 
(1 : 1,000), which are injected with an ordinary urethral syringe with a 
capacity of about two drachms. The pain and distress following the use 

of these injections are very in- 
tense, but when successful the 
sero-sanguinolent discharge, 
which subsequently appears, 
subsides in a day or two of its 
own accord. This treatment is harsh, and seldom employed 
for this reason, and because the patient is not seen early 
enough. Its success depends upon the destruction of the 
gonococci before they have penetrated beneath the epithelial 
lining of the urethra. 

Astringent Injections. — Injections of the urethra are 
capable of rendering considerable service in urethritis, but 
Fig. 1. when improperly used they may occasion much mischief. 

In gonorrhoeal urethritis, if they are used at the be- 
ginning of the disease, there is grave danger of carrying the inflamma- 
tion backward and of lighting up posterior urethral complications, espe- 
cially when the agent employed possesses astringent properties only 
and is not destructive to the gonorrhoeal virus. 

In specific urethritis, then, if the local treatment is not directly antag- 
onistic to the life of the gonococcus, such as may be obtained by copious 
irrigations of the urethra with permanganate of potassium or by the local 
application of the silver preparations, it is far better to follow the treat- 
ment advised by Fournier, Guiard, and others, and postpone all local 
measures until the later stage, when the acute symptoms shall have 
subsided. It is at this late stage that the judicious use of a mild astrin- 
gent injection may sometimes be of service. 

Frequently in subacute urethritis and in non-specific cases generally 
one of the astringent injections may be employed with good effect. It 
is often the case, however, that the discharge, which is checked by the 
use of an injection, promptly returns when such injection is discontinued. 
This relapsing urethritis is generally due to morbid changes in the urethra 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 27 

and to "imderlying constitutional conditions. Such cases of relapsing 
urethritis which persistently recur properly come under the head of 
chronic urethritis (vide page 37) . 

A final precaution concerning the use of injections is that they occa- 
sionally produce and keep up a discharge on account of being inappro- 
priately strong. This is quite likely to occur with those patients who 
frighten themselves into the belief that they have gonorrhoea when such 
does not exist, and who commence a fierce onslaught on the urethra with 
injections— a treatment which promptly excites a flow of pus and confirms 
their fears. On the other hand, at the end of a gonorrhoea, when an 
injection of undue strength has been employed to arrest the discharge, 
an oozing of gleety mucus may keep up, maintained by the use of a 
strong injection which is persisted in. 

In either one of this class of cases rapid improvement follows a cessa- 
tion of the injection. 

In injectiug the urethra a proper syringe should be used, one which 
is not too blunt nor yet which is made with too long a nozzle. This 
may be varied according to the size of the meatus in an individual case 
(Eig. 1). In order to obtain the proper degree of distention, of the 
canal, the capacity of such a syringe should be between 2 and 3^ drachms. 
The syringe is filled with the injection and the air expelled. The penile 
end is introduced snugly within the mouth of the meatus and the fluid 
injected by making firm, steady pressure upon the piston. The contents 
of the syringe having been thus emptied into the urethra, the latter is 
withdrawn and the fluid retained by closure of the meatus with the 
thumb and index finger for ten seconds for an astringent injection; much 
longer when the object is to destroy micro-organisms as with one of the 
silver preparations. It is always proper to urinate before making the in- 
jection, thereby emptying the canal of any accumulated discharge. 

The different astringent preparations used for urethral injection are 
zinc sulphate, sulpho-carbolate, and permanganate, alum, subacetate of 
lead, bismuth, and fluid extract of hydrastis. One of the following 
f ormulse may be employed : 

i^ Zinci sulphatis, gr. iij.-vi. 

Liq. plumbi subacetatis dilut., . . . . | iv. 

M. To be filtered. 

I^ Zinci sulphatis, . . . . . . . gr. iv. 

Bismuth., . . . . . . . . ; 3 ij. 

Pulv. acacise, 3 i. 

Aquae, . . . . . . . q. s. ad § iv. 

M. To be well shaken. 

"Bf Zinci permanganat. , gr. i.-iv. 

Aquae, § iv. 

M. 



28 VENEREAL. DISEASES. 

i^ Zinci sulphatis, ........ gr. ij.-iv. 

Ext. hydrastis fld., 3 i.-iv. 

Aquse, . . . § iv. 

M. 

I^ Aluminis, gr. iv.-viij. 

Zinci sulphatis, gr. ij.-iv. 

Aquse, . . . . . . . . . § iv. 

M. 

The frequency with which the above astringent preparations should 
be used must be governed by the quantity of the discharge and the con- 
trolling influence exerted upon it by the injection. A proper rule to 
follow is to use the injection only sufficiently often to keep the discharge 
in check. When the discharge persists in spite of its usage after a rea- 
sonable length of time, or when relapses occur as often as the injection 
is discontinued, it may be taken as an indication that the agent employed 
is acting as a source of irritation rather than a means of relief, or that 
there is trouble deeper down the canal than is reached by the injection 
(posterior urethritis) or perhaps deeper in the tissues themselves. 

Urethral and Intra- Vesical Irrigations, — The method of irrigating the 
urethra in the treatment of gonorrhoea is not new. It was used over five 
years ago by different investigators, notably by Halstead, of Baltimore, 
and Brewer, of New York, who employed the bichloride of mercury for this 
purpose. More recently the permanganate of potassium has come into 
popular favor on account of its marked destructive action upon the gono- 
coccus, and of the admirable results reported in its use by Janet, of Paris, 
who has carefully laid down a method of treatment which bears his name. 

Janet's method is shown in the accompanying table, which is extracted 
from the treatise of Dr. Desnos, of Paris:' 



First day , 



Second day. 
Third day . . 
Fourth day . 
Fifth day . . 
Sixth day . . 
Seventh day 
Eighth day. 
Ninth day . . 
Tenth day . . 



8 A.M. 



*A. U. 1:3,000... 
t A. P. U. 1 : 2,000 



t A. P. U. 1 : 2,000 



A. U. 1 : 500. 





Afternoon. 


*A. 


U. 


1 


1,000. .. 


fA. 


P. 


u. 


1 : 2,000 



fA. P. U. 1 
+ A. P. U. 1 
t A. P. U. 1 
f A. P. U. 1 
f A. P. U. 1 



2,000 
1,000 
1,000 
1,000 
1,000 



9 p.m. 



* A. U. 1 : 4,000 

7 p.m. 

* A. U. 1 : 4,000. 

t A. P. U. 1 : 4,000 
f A. P. U. 1 : 4,000 



* A. U. = anterior urethral irrigation. 

f A. P. U. = anterior and posterior urethral irrigation. 

The anterior irrigation is conducted by means of a conical-shaped 
nozzle fitted to the meatus, and a fountain syringe or irrigator. The 



"Traite elementaire des Maladies des Voies urinaires," par le Dr. E. Desnos, 



1898 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 



29 



posterior urethra is irrigated with the same nozzle hj distending the 
anterior urethra with the solution and raising the reservoir to a height 
sufficient to overcome the resistance of the cut-off muscle (between six and 
eight feet) . The method of Janet, as shown in the above table, is too 
dogmatic. The treatment can be best utilized by varying the strength of 
the permanganate solution according to the susceptibility and sensitive- 
ness of different urethras. We find that weaker solutions in the begin- 
ning of the disease are better 
tolerated and produce the same 
results. 

It is entirely unnecessary 
in the early stages of the dis- 
ease to extend the irrigation to 
the posterior urethra. In some 
cases recovery occurs before 
this region is reached by the 
disease when it need not be in- 
vaded by the treatment at all. 
In other cases not so favorable, 
at the expiration of a week or 
ten days, the proximity of the 
inflammation is likely to be 
such that the posterior canal . 
should be irrigated as a matter 
of precaution if not necessity. 

The method of forcing the resistance of the cut-off muscle is also un- 
necessary, and is likely to cause undue irritation when the inflammation 
of the urethra is acute. Swelled testicle has often been produced by it. 
Even if it be a safe procedure in the hands of one specially trained and 
practised in its use, it is not proper to advise it as a routine method. 

In employing the Janet method we begin with a solution of 1 : 5, 000 
or 6,000 permanganate of potassium, and increase the strength during the 
first week up to 1 : 4,000. The treatment is given once or twice daily in 
the early stage of the disease ; generally once a day is sufficient to keep 
the discharge under control, if not it should be employed twice daily. At 
the end of the first week or ten days the irrigation includes both the 
anterior and posterior urethras, unless the case has proved a very tractable 
one and all symptoms have subsided before this period. This treatment 
is not stopped abruptly, but continued after the discharge has ceased and 
both flows of urine are clear, at which period an interval of one or two 
days is allowed to intervene between the treatments. The method of 
applying this treatment, which has proved most satisfactory, is carried 
out by means of a special instrument (Figs. 4, 5, 6) designed for this pur- 
pose, and enables the operation to be conducted without damage and with- 




FiG. 2.— Chetwood's Alternating Shut-off. 



30 



VENEREAL DISEASES. 



out dirt. It permits a moderate amount of distention of the canal, wMch 
is essential, and provides for the emptying of the urethra without with- 




FiG. 3. — Clietwood's Urethral Nozzles. 

drawal of the nozzle of the instrument. A catheter was formerly used 
for irrigating the anterior urethra, but is unsatisfactory as it does not 
produce a proper distention of the canal. An ordinary cone-shaped nozzle, 
which must be withdrawn after each inflation to empty the canal, is un- 
wieldy and less cleanly. 

The distinctive parts of this apparatus for urethral and intravesical 
irrigation consist of a glass nozzle (Fig. 3), which has one large open- 
ing at its penile extremity, connecting with two arms, one for the inflow 
and one for the outflow current, and the alternating shut-off (Fig. 2), 




Fig. 4.— Anterior Urethral Irrigation. The irrigating fluid Is allowed to All the nozzle to displace the 
air before coupling, and is retained by the little finger over the exit tube. 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 31 

which is intended to open and shut the tubes attached to the two arms of 
the nozzle alternately ; so that by impeding the outflow current, when the 
fluid enters the urethra, an even distention of the canal is produced ; and 
by obstructing the inflow current after the urethra is full, complete ejec- 
tion of its contents is insured. The amount of distention is regulated 
by the height of the reservoir, four and a half to five feet being sufficient 
to irrigate the entire anterior section of the canal and produce the proper 
amount of distention. The pressure may be varied when pain is com- 




FiG. 5.— Anterior Urethral Irrigation. The foreskin is retracted and the nozzle coupled with the 
meatus, when the fluid is allowed to enter the urethra by opening the shut-off, 

plained of, by partially closing the inflow tube. This apparatus may be 
used to irrigate the posterior urethra without a catheter by elevating the 
reservoir sufficiently to overcome the resistance of the cut-off muscle (six 
to eight feet) . In acute urethritis it is well to employ the catheter for 
posterior irrigation, having previously thoroughly irrigated the anterior 
canal. 

For posterior urethral irrigation a No. 6 or 7 English catheter is care- 
fully lubricated ^ and slowly introduced until a few drops of urine indicate 
that the bladder is reached. Before attaching the irrigating tube to the 
catheter the bladder is completely emptied, after which the catheter is 
withdrawn about one inch so as to direct the flow between the membra- 

' A soluble lubricant should be employed so as not to arrest the action of the 
irrigating fluid. "Lubri-chondrin," which is made from Irish moss, and several 
saponaceous lubricants possess this property. 



O^A VENEREAL DISEASES. 

nous and prostatic urethras and thus insure distention of the entire pos- 
terior urethra. When the bladder is filled the catheter is entirely with- 
drawn and the patient is told to void the vesical contents by urinating. 
About one quart of solution is used for anterior irrigation and from eight 
to twelve ounces for the posterior portion, according to the capacity of 
the bladder. 

It is of great importance in acute urethritis to irrigate thoroughly the 
anterior urethra before introducing the catheter into the posterior canal. 




Fig. 6.— Anterior Urethral Irrigation. The urethra being distended the shut-off is closed, which opens 
the outflow tube and the urethra promptly empties. 

Attention to this detail may be the means of avoiding unnecessary com- 
plications. 

The permanganate of potassium irrigations, while used more particu- 
larly in specific urethritis, are also applicable to the treatment of non-speci- 
fic cases, notably those in which the discharge is profuse and purulent, the 
difference in the management being that it is rarely, if ever, necessary 
in the latter form to irrigate more than once a day, and the posterior 
urethra need never be invaded unless it is apparent that the inflammation 
is located in this region. 



The Topical Use of the Silver Compounds. 

The nitrate of silver has long been employed as a topical application for 
inflammatory conditions of the urethra. Its use as an abortive measure in 
gonorrhoea has already been referred to. Its value depends upon its bacter- 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 33 

icidal action, which is especially directed against the gonococcus. In view 
of this valuable property of the silver salts and of certain disadvantages 
attribnced to the nitrate, there have been introduced several new silver com- 
pounds, all of which claim to possess the bactericidal action of the nitrate 
and to be devoid of its objectionable features. These preparations are 
the citrate of silver of Crede, argentamin, argonin, and protargol. The 
nitrate of silver is a good local antiseptic for urethral use in solutions 
from 1 : 2,000 to 1 : 500. It is applicable to both the specific and non- 
specific forms of acute urethritis. It is applied to the anterior urethra by 
means of an ordinary urethral syringe (Fig* 1) or with the Keyes-Ultz- 
mann syringe (see Mg. 18, page 46) ; but the beneficial effects of this and 
of all the silver preparations are more especially obvious in the last stage 
of urethritis, when the acute symptoms have subsided, notably as a deep 
urethral application in posterior urethritis by means of the deep urethral 
syringe. The nitrate of silver is thus employed in increasing strength, be- 
ginning at 1 : 1,000 and increasing according to the tolerance of the ure- 
thra in each individual case. Such applications are made at intervals of 
one, two, or three days, and are often the means of terminating the last 
stage of a gonorrhoea after it has reached the deep urethra. 

The disadvantages attributed to the nitrate of silver are that it stains 
the linen and the hands, is more or less irritating, and that it precipitates 
the albumin of the tissues, thus limiting its range of action. Regarding 
these objections, the first renders it unsuitable for the patient's own use; 
the second depends more or less upon the strength of the solution and the 
individual susceptibilities of different urethras, while in spite of the third 
objection it seems to exert its influence somewhat deeper than the perman- 
ganate of potassium does, although it does not check the discharge, when 
copious, as well as the latter remedy. The citrate of silver and argenta- 
min will not be found less irritating than the nitrate or more effective. 
Argonin may be used in much stronger solutions without causing irrita- 
tion (five to ten per cent) , but relapses sometimes occur during its use in 
acute specific urethritis, showing that it permits the gonococcus to get 
beyond its reach. 

Protargol has been used in the clinic of Lewin and Frank of Berlin, 
and by Neisser, apparently with gratifying results in acute gonorrhoeal 
urethritis. Its employment is recommended in a solution of one-half to 
0D3 per cent, to be retained in the urethra for half an hour once a day 
and ten minutes twice a day. The gonococci are said to disappear per- 
manently from the urethra in from two to five days. When used in the 
last stage of gonorrhoea in the posterior urethra in place of the nitrate, it 
should be employed in stronger solutions than in the anterior urethra, 
beginning with two and a half per cent and working up, if possible, to 
ten per cent. In this stage we believe it to be of more value than in the 
acute condition, in which it is inferior to the permanganate of potassium. 
3 



34 



VENEREAL. DISEASES. 



The claims of superiority of these various silver compounds over the 
nitrate are not universally indorsed. When the daily office attendance 
necessitated by the irrigation treatment is too exacting upon the patient 
in cases of specific urethritis, a five-per-cent solution of argonin or of 
one-half per cent protargol may be ordered for the patient's own use, to 
be employed by means of an ordinary urethral syringe, with a capacity 
of 2 or 2^ drachms two or three times daily, and good results may follow 
such treatment. In some instances these injections have been employed 
in conjunction with the permanganate of potassium irrigations. This 
combination of both the irrigations and the silver preparations applies, 
of course, to the specific form of the disease. 

A resume of the local means to be adopted in the treatment of acute 
urethritis is as follows : When the conduct of the treatment can be entirely 
under the control of the surgeon, the good results attained by the use of 
copious irrigations of the urethra with permanganate of potassium strongly 




Fig. 7.— Gonorrhoea Bag. 

recommend this mode of treatment before all others. The silver prepara- 
tions, argonin and protargol, may be used by the patient in specific ure- 
thritis when the more exacting treatment is impracticable. A- combina- 
tion of the irrigation treatment with the judicious use of one of the silver 
preparations is serviceable in some cases of acute specific urethritis. The 
application to the posterior urethra of the nitrate of silver or of protargol 
will often assist in terminating the last stage of urethritis, and it is at 
this period that the silver preparations seem to exercise their most bene- 
ficial effect. 

Einally the use of the astringent injections by means of an ordinary 
urethral syringe is more applicable to subacute non-specific cases of ure- 
thritis, although sometimes of service in the declining stage of gonor- 
rhoea, when the specific element has been destroyed. 

The dressings of the penis in urethritis when the discharge is abundant, 
become a matter of importance, and may prevent the occurrence of bala- 
nitis and posthitis, and vegetations around the foreskin', all of which 
conditions are frequently due to the collection of irritating discharges. 



SPECIFIC AND NON-SPECIFIC URETHRITIS — GONORRHCEA. 



35 



When the discharge from the penis is slight and of a non-purulent 
character, a plug of cotton, dry or moistened with mild sublimate solu- 
tion, placed over the meatus and retained by the prepuce, may be a 
sufficient dressing; but when copious it is necessary to provide some- 
thing better to catch the flow and protect the clothing. Gonorrhoea bags, 




Via. 8. 




Fig. 9. » Fig. 10. 

Figs. 8, 9, and 10.— Dressing for Gonorrhoea. 

made of rubber or muslin, are sold by druggists for this purpose (Fig. 
7). The bag is suspended from the waist by means of tapes, and a 
piece of absorbent cotton, dry or moistened with an antiseptic solution, 
is placed inside. The cotton should be changed frequently. Another 
satisfactory dressing, worn in connection with an ordinary suspensory 
bandage, consists of a piece of absorbent gauze, folded in the shape of £| 



36 



VENEREAL DISEASES. 



triangle. The base of this, about ten inches wide, is placed underneath 
the penis, and the three corners are folded over and pinned together to the 
band of the suspensory (Figs. 8, 9, 10). Such a dressing may be changed 
as frequently as is necessary, according to the amount of discharge. In 
all cases general cleanliness should be strictly observed. The discharge 
should not be allowed to accumulate behind the foreskin. A mild anti- 




G.TIEMANM&CO 



Fig. 11.— Taylor's Duckbill Syringe. 



septic wash should be employed daily, and if the foreskin cannot be 
retracted, a duckbill syringe (Fig. 11) should be used to wash the cav- 
ity of the prepuce. For purposes of general cleanliness, as well as when 
balanitis or posthitis exist, a solution of corrosive sublimate, 1 : 6,000 or 
8,000, may be used, or the following astringent and antiseptic lotion: 



I^ Thymol, 

Sulpho-carbolate of zinc, . 

Boracic acid, 

Fluid extract of hydrastis (colorless). 
Aqua gaultherise, .... 



, gr. 1. 

• gr. i- 

• 3i. 

> 3ij. 
s. ad 5 iv. 



CHAPTER II. 

CHEONIC UEETHKITIS. 

Etiology. — Chronic uretliritis is generally the result of a prolonged, 
neglected, or ill-treated gonorrhoea. It may occur, however, independ- 
ently of gonorrhoea, notably in subjects of a gouty, rheumatic, or tubercu- 
lous diathesis. It also seems to be the case that tuberculous and rheumatic 
subjects who acquire gonorrhoea are more liable than others to posterior 
urethritis and other complications, as well as to the protraction of the 
malady into the chronic condition commonly called gleet. 

Clinically speaking, we recognize several forms of chronic urethritis : 
First, one which is in direct continuation of recent acute inflammation, 
in which the symptoms are pronounced and the discharge of a variable 
character, often rather free. This may last anywhere from three to six 
months, even longer. 

In the second form the discharge is decidedly scanty, and has been 
present for a much longer period — perhaps for years. 

A third form shows itself as a continual tendency to recurring attacks 
of acute or subacute urethritis, between which there may be practically 
no signs of trouble. These several forms are dependent upon various 
causes. The first may be due to the continued stay of the gonococcus in 
the urethra, to constitutional debility, to the existence of complications, 
or to badly directed treatment, and sometimes to too long continued or 
too energetic local measures. The second and third forms are generally 
dependent upon stricture or other morbid changes in the urethra or 
adjacent structures, catarrhal and mildly inflammatory conditions excited 
into activity by various causes — intercourse, alcohol, fatigue, etc. — or are 
dependent upon diathetic conditions, gout, scrofula, tubercle, etc. Ac- 
cording to some recent investigators it is rare to find the gonococcus in 
very old cases of chronic urethritis. 

Pathology.^ — When the urethra has been the seat of several attacks of 
acute and intense gonorrhoea, notably if complicated and not properly 
controlled by treatment, the general tissue and follicles are apt to become 
structurally altered in a mild, chronic, inflammatory way, and thus to 
render the subject prone to frequent acute outbreaks from causes which 
do not affect the mucous membrane when it is healthy. Chronic urethritis 
may be located in the anterior or posterior urethra, or both. A favorite 
site in the anterior urethra is the sinus of the bulb, but the trouble may 
be disseminated throughout the spongy portion. The morbid changes 



38 VENEREAL DISEASES. 

consist in alterations in the color and transparency of the mucous mem- 
brane, structural changes in the epithelium, alterations in the follicles 
and glands, which may become distended with retained pus, their ducts 
being dilated or occluded, or the glands may become obliterated as the 
result of formation of new fibrotic tissue. Finally granulations form on 
the surface of the mucous membrane, a starting-point of stricture. In 
the posterior urethra the changes are more or less analogous, but, owing 
to the structures liable to be involved, the condition here becomes more 
important and the symptoms are more complex. The mucous membrane 
is swollen and congested ; the veru montanum elevated and softened ; the 
glands and follicles present the same changes as in the anterior urethra, 
and one or both of the ejaculatory ducts may become catarrhal or even 
occluded. The inflammation in the prostatic canal may result in engorge- 
ment of the neck of the bladder, and eventually in contracture of the 
sphincter (see Prostatitis). 

Symptoms. — In chronic anterior urethritis the discharge is continuous. 
It may be slight and the quantity may be greater on rising in the morn- 
ing, but this is due to over-night accumulation. It may be so scanty as 
to cause a slight glueing together of the meatus, or, on the other hand, 
it may be continuously copious. In the latter instance the existence of 
anterior urethritis is self-evident, although there may coexist posterior 
urethral inflammation. The discharge is practically the only symptom 
present in chronic anterior urethritis, as there is generally no pain or 
other discomfort. By obtaining the urine in two separate flows it will 
be seen that the second is perfectly clear ; or, having previously washed 
out the anterior canal, the urine voided will be found entirely free from 
pus. If a conical bulbous bougie be passed into the anterior urethra (a 
bulb as large as the meatus will admit) down to but not into the mem- 
branous portion, when the urethritis is confined to the anterior canal, a 
tender spot may be detected somewhere along the urethra during the 
introduction of the instrument; and when it is withdrawn, a small 
amount of pus will generally be found upon the shoulder of the bulb. 
The damaged area in this manner may be located in the bulb, in the 
fossa navicularis, or in some part of the urethra between these points. 
In the case of multiple strictures the site of the inflammatory area will 
be found behind the points of contraction. 

In chronic ^posterior urethritis, unless accompanied by anterior inflam- 
mation, the discharge is intermittent. When slight it appears only in 
the passage of the urine, but when more abundant collects at the meatus 
in the form of a morning drop, or the flow may be provoked by the act 
of straining at stool. There is not uncommonly a certain amount of 
frequency of urination ; the desire is urgent but not imperative, and ac- 
companied by more or less burning at the end of the penis. When the 
pain and the desire to urinate persist after the urine is voided, it is an 



CHRONIC URETHRITIS. 



39 



indication that the neck of the bladder is involved, and when there is 
pain in the perineum in the intervals between urination, there exists in 
conjunction with the urethritis a prostatitis. In exploring the urethra 
with a blunt steel or bulbous instrument, after previously washing the 
anterior canal, it will be noted that no pus is expressed from the anterior 
region; but as soon as the posterior urethra is reached, a sharp pain is 
produced, and the withdrawal of the instrument is accompanied by a dis- 
charge of pus. Of course when this condition exists in a very mild de- 
gree, the amount of discharge obtained may be minute, but the sensitive 
area will have been located in the region where the trouble exists. 

Endoscopic examination is useful for the anterior urethra, and will 
reveal the general condition of the mucous membrane. The mouths of 
distended follicles may be distin- 
guished if pus exudes from them, 
and we may detect the presence of 
granulations or warty excrescences on 
the urethral surface. For the pos- 
terior urethra the endoscopic exami- 
nation is less useful. It is produc- 
tive of great pain, and sometimes 
the source of unnecessary irritation. 

Diagnosis. — In reaching a diag- 
nosis regarding the location of chronic 
urethritis, it should be remembered 
that the discharge is liable to be 
continuous in anterior and intermit- 
tent in posterior urethritis ; that the 

symptoms of urgent, frequent, and painful passage of the urine are absent 
in anterior and may or may not be present in posterior urethritis. Unless 
there coexist a certain amount of cystitis, these latter symptoms are not 
marked. The urine should be voided in two separate glasses, the urethra 
having been previously carefully washed with plain lukewarm water. 
The washings will thus contain the product of the front urethra, the first 
flow of urine the posterior urethral pus, and the second the urine as it 
exists in the bladder. The bulbous bougie or blunt sound will detect the 
contracted or sensitive areas, and in making these explorations it is 
important to separate in the examination the anterior and posterior por- 
tions of the canal. 

Urethroscopy is an additional means of diagnosis, and in some 
instances renders important service. For this purpose various instru- 
ments have been devised, the principal difference being in the manner of 
obtaining the required light for direct observation of the urethral tract. 
The simplest and most available method for ordinary usage is the head 
mirror. Instead of a head mirror an electric head lamp with a condenser 




Fig. 12.— Electric Head Lamp. 



40 



VENEREAL DISEASES. 



has been devised (Fig. 12) . Another means of reflecting the light into 
the urethra is obtained by the Otis urethroscope, in which the reflector and 




iS^ 



Fig. 13.— Otis Urethroscope. 



light are connected directly with the endoscopic tube (Fig. 13). The more 
complicated recent device, the Oberlander-Nitze urethroscope, brings the 
light within the urethra by the use of a platinum wire, which is heated to 
incandescence (Fig. 14). This requires the addition of a cooling apparatus 




Fig. 14:.— Oberlander-Nitze Urethroscope. 

to enable the urethra to withstand comfortably the presence of the light 
and involves the employment of an expensive and complicated attachment. 
A new urethroscope has recently been devised which is an improvement 
on previous makes and has the light within the urethra. It is a modifi- 
cation of Kollman's modification of the Oberlander instr anient, the prin- 




FiG. 15.— Klotz Endoscopic Tube. 



cipal feature being that no cooling apparatus is required. For urethro- 
scopic examination we may employ a speculum or an endoscopic tube 
(Figs. 15, 16, and 17) of a size suitable to the capacity of the urethra 
(Plate VIII.). 



I 



KEYES AND CHETWOOD. 



PLATE VIII. 




1. Instrument In use 
with endoscopic tube. 

2. Same, with wire spec- 
ulum In place of tube. 

3. Mignon incandescent 
lamp used for illumination. 

4. Light carrier with pro- 
tected lamp for use in a 
speculum. Especially use- 
ful for Intra-urethral opera- 
tions. Does not burn the 
canal. 

5. Unprotected lamp 
used with light carrier in 
endoscopic tube for ordi- 
nary urethroscopy. 

6. Apparatus complete, 
with battery. Dimensions, 
10 in. X b}4 In. X 234 in. 




CHETWOOD URETHROSCOPE, FOR DIRECT ILLUMINATION OF THE URETHRA WITHOUT HEAT. 



CHRONIC URETHRITIS. 



41 



It is possible for the ordinary observer to recognize granulations, 
papillomata, and erosions in tlie different portions of the anterior ure- 
thra, but it requires the eye of an accomplished and prac- 
tised worker to interpret the various endoscopic pictures of 
a less definite and more complex character which are some- 
times described, and by an intelligent adoption of the other 
methods in vogue it will be found that it is only in excep- 
tional cases that urethroscopy is essentiaf to obtain a satis- 
factory diagnosis. 

As already stated, direct examination of the posterior 
urethra is more difficult and less satisfactory. 

When the symptoms of urethritis point toward the 
existence of inflammation of the prostate gland, 
digital examination by rectal touch will deter- 
mine the condition of this organ as 
well as that of the seminal vesicles. 
The existence of cystitis in conjunc- 
tion with urethritis will be recognized 
by the symptoms and by the examina- 
tion of the urine. These complica- 
tions are to be considered in a later 
chapter. 

Treatment. — The treatment of 
chronic urethritis must be varied ac- 
cording to the nature and character of 
the malady. In that class of cases in 
which the inflammation is a direct con- 
tinuation of recent acute urethritis, all 
the restrictions as regards the use of 
stimulants, sexual excitement, etc., 
are to be enforced as in the acute con- 
dition. Indeed its prolongation into rm. 16.— Otis Endoscopic Tubes. 
the chronic stage is often due to a 

failure to observe these precautions. As already stated, chronic urethri- 
tis may be due to the continued stay of the gonococcus in the urethra, 




Fig. 17.— Brown's Urethral Speculum. 



42 VENEREAL DISEASES. 

to the existence of one of the various complications which occur during 
the acute stage, to constitutional debility, and sometimes to too long- 
continued local treatment. That class of cases in which the discharge is 
very slight, and has existed for a considerable period, is generally more 
difficult to treat. The cause is apt to be some structural change in the 
canal itself, or extension of inflammation to the adjacent structures. The 
treatment of these cases therefore entails the discovery of the underlying 
cause and its treatment by proper measures. Stricture of the urethra, 
chronic prostatitis and vesiculitis are common causes, and are considered 
in a separate chapter. 

Finally, those cases which appear as frequent relapses of urethritis 
from causes which should not affect the healthy urethra, are generally the 
result of changes wrought in the tissues by the previous inflammation, 
and more often occur in subjects of a tuberculous, gouty, or rheumatic dia- 
thesis. In studying the various forms of chronic urethritis we must take 
into consideration the following elements, which may enter into any given 
case: 

1. The presence of the gonococcus in the urethra. 

2. Too long-continued or irritating local treatment. 

3. Structural changes in the urethra and extension of inflammation to 
the neighboring parts. 

4. Constitutional debilitv and diathetic conditions. 

A careful analysis of each case should discover one or more of the 
above causative factors, and determine the course of treatment to be 
followed. When rigorous local measures have been pursued for a long 
period without controlling the discharge, often by instituting a simple 
antiphlogistic regime, more favorable results will follow. Under these 
circumstances, the cessation of local measures and the use of internal 
medication alone or in conjunction with milder local means should be tried. 

When the gonococcus is discovered in the discharge from the urethra 
local measures to antagonize its presence there should be adopted. Local- 
ized morbid conditions in the canal or adjacent structures should besought 
out and treated according to the indications. Concomitant constitutional 
disorders should as far as possible be corrected by rational treatment. 

Internal Treatment. — The nearer a case of chronic urethritis ap- 
proaches to the acute form in its character, the more appropriate are those 
internal remedies referred to in the treatment of the latter malady. Thus 
when the discharge is more or less free, the use of the oil of sandal wood 
or of oil of gaultheria alone, or in combination with an alkali, is indicated. 
The oleoresin of cubebs and the oil of turpentine are suitable for the more 
chronic and less active forms ; tt[ v. to xx. of the former or V\ v. to x. of 
the latter may be given three times daily. The oil of eucalyptus is some- 
times given with good effect, TTt v. to x. three times a day. When the poste- 
rior urethra or the adjoining portion of the bladder is the seat of trouble, 



CHRONIC URETHRITIS. 



43 



attention is called to a greater or lesser amount of urinary tenesmus and 
urgency, which may be present. For this train of symptoms the tincture 
of hyoscyamus and the fluid extract of corn silk are useful adjuvants ; 
ni, XV. to XXX. of the former and 3 ss. to 3 i. of the latter may be given 
after each meal in combination with the other remedies. When the urine 
is highly concentrated and irritating it should be diluted by the free use 
of diuretic mineral water. The tincture of hyoscyamus and fluid extract 
of kava kava both have desirable diuretic properties, and may be given 
for this purpose, exerting at the same time a certain amount of sedative 
influence upon the posterior urethra. Finally, iron, cod-liver oil, and 
hypophosphites are to be used when the general health calls for such 
medication. 



Formula. 



^ 



M 



01. gaultherise, . 
Potass, cit., 
Tinct. hyoscyami, 
Ext. M. stigmat. maidis, 
Syr. acaciae, 
S. Teaspoonful t.i.d. 



S. 
Or: 



Capsul. ol. terebintti., 
One or two t.i.d. 



Capsul. ol. eucalyptus, 
One or two t.i.d. 



. I ss. 
. 3ij. 
. 3vi. 

q.s. ad § iij. 

. TTIV. 



TTl V. 



Or 



M. S, 
M 



Capsul. ol. santal., 

One or two capsules t.i.d, 

Capsul. oleoresin. cubebse, 
Four to six capsules daily. 

Bals. copaibse, 

01. gaultherise, .... 
Liq. potass., . . . 
Syr. acacise, .... 
, Teaspoonful t.i.d. 

Ext. fld. kavae kavse, 

Ext. fld. stigmat. maidis, . 

S. One to two teaspoonfuls t.i.d. 



TTIX. 
TTIX. 



aa I ss. 
. 3 iij. 
q.s. ad I iij. 



aa I ij. 



Local Treatment. — The statement made concerning internal medication 
should be repeated here, that the nearer the character of the symptoms 
of chronic urethritis approaches the acute form the more suitable are 
those measures employed during the acute stage. Thus when the dis- 
charge is free and purulent, the use of irrigations of permanganate of 
potassium, both to the anterior and posterior urethra, is indicated. The 
permanganate of potassium and the silver preparations are especially to 



44 VENEREAL DISEASES. 

be relied upon when the presence of the gonococcus has been demon- 
strated. Instrumental dilatation of the urethra once or twice a week in 
connection with the other treatment of chronic urethritis, aside from its 
employment in stricture of the canal, is at times a desirable measure. 
Such dilatation opens the follicles of the urethra and expresses their con- 
tents, keeps down granulations, and lessens irritability and tendency to 
spasm. Some urethras rebel against any instrumental interference, and 
should not be submitted to it except from strict necessity. The smooth 
steel sound, deftly handled, is the least irritating urethral instrument. 
The largest size that the meatus will admit should be employed, and no 
undue force used in its passage. Other dilating instruments have been 
devised, and are used for the same purposes as the sound. They are 
constructed so as to be expanded to any size after introduction, the size 
being indicated on a dial at the handle (p. 133). They are also made to 
combine dilatation with irrigation. The objection to dilators generally 
has been that the blades of the instruments which are covered with a 
soft-rubber hood make a less even distention than the sound and cause 
more irritation. By having a sound which is tapering in both directions 
(Fig. 67, page 126), the meatus need not be submitted to the same amount 
of distention as the lower portion of the canal, while the sound is doing 
its work at the point where distention is most needed. 

Urethral medication is effected by means of irrigations, instillations, 
injections, soluble bougies, antiseptic applications, and cupped sounds. 

By means of injections or bougies the patient can, if desired, conduct 
the local treatment himself when it is confined to the anterior urethra. 
Injections are by far the more satisfactorj^ 

The other methods mentioned are carried out by the surgeon. 

Cupped sounds are intended to be used for the application of ointment 
to the surface of the urethra, but are not so much in vogue at the present 
time as they were formerly. 

The use of the endoscope is often irritating, and should be confined to 
those cases in which there exists a well-defined local lesion which can be 
readily reached, such as a papilloma or ulceration. 

It is a mistake to proceed to the treatment of any case of chronic ure- 
thritis in a routine manner. A proper analysis of each case will greatly 
assist in the selection of treatment. The existing lesion should, if pos- 
sible, be located, and any functional irregularity or constitutional dis- 
turbance taken into account. 

Many cases of chronic urethritis (anterior or posterior) get well as the 
result of well-directed local treatment, while others get well when local 
treatment, which has been too long continued, is stopped. Some pa- 
tients who are undermined in general health, or the subjects of the tuber- 
culous or scrofulous diathesis, either improve or get entirely well when 
transplanted to a favorable climate, while those patients in whom the ure- 



I 



CHRONIC URETHRITIS. 45 

thritis is due to structural changes in the canal (stricture, etc.) necessarily 
do not improve unless treatment be directed against the actual lesion. 

The use of astringent injections by the patient is sometimes of value 
in correcting a simple catarrhal condition, and may control the discharge 
from the anterior urethra. They are also used to supplement the local 
treatment conducted by the surgeon, or when enforced absence of the 
patient precludes the adoption of other measures. For this purpose one 
of the astringent injections given on page 27 may be ordered. 

Urethral bougies are cylinders of cacao butter containing some medica- 
ment. They are retained in the urethra, and, melting, liberate the drug. 
In this manner the nitrate of silver, sulphate of copper, sulphate of zinc, 
iodoform, and numerous other substances have been employed. This 
form of medication is sometimes a source of irritation and the means of 
lighting up fresh inflammation, and has nothing to recommend it in 
preference to the more popular methods in use. 

Irrigations of permanganate of potassium of mild strength (1 : 8,000 
to 1 :4,000) are best suited to cases in which the discharge is profuse or 
the urine more or less turbid with pus. Its favorable effects are generally 
so promptly obvious that when some improvement is not noted soon after 
a short trial, it may be safely concluded that the permanganate is not 
what is required, and recourse should be had to other means of relief. 

The anterior urethra alone is irrigated when the trouble is confined 
to this region. The method has been already described (p. 29). When 
the posterior urethra is the seat of trouble, posterior irrigation is em- 
ployed, always after previously irrigating the anterior canal, if there be 
any evidence of trouble in that part. 

These irrigations are generally made at intervals of one, two, or three 
days, according to the amount of pus secreted and the control exercised 
upon this secretion by the treatment, until a stationary period is reached, 
as evidenced by the cessation of the discharge and the reduction of the 
pus in the urine to a minimum quantity. Sometimes no other treatment 
is required, but a certain amount of inflammation may persist which tends 
to remain under the permanganate more or less stationary, and may be 
benefited by the substitution of one of the other local applications, more 
astringent in action and somewhat more penetrating. At this period 
instillations are frequently found useful, and in some cases of chronic 
urethritis prove more effective than the permanganate irrigations from, 
the very beginning of the treatment. 

Instillations are suitable for both the anterior and posterior urethra. 
They are employed with the Keyes-Ultzmann or Guyon syriq,ges (Figs. 
18 and 19), by means of which small quantities of solutions possessing 
astringent, antiseptic, and mildly caustic properties are distributed along 
the course of the canal. The Guyon instrument consists of a flexible 
gum-elastic catheter with a bulbous end, having a small opening at the 



46 



VENEREAL DISEASES. 



top. A Pravaz syringe is fitted to the catheter, and its contents are ejected 
drop by drop by turning the piston, which is a screw. The Keyes in- 
strument is solid in one piece, consisting of a silver catheter with fine 




Fig. 18.— Keyes' Deep Urethral Syringe. 

lumen and proper urethral curve, attached to a small syringe, the piston 
of which is graduated in minims. The introduction of this latter syringe 
is seemingly less irritating than that of a bulbous instrument, and permits 
the application of the liquid to any portion of the canal, whether in the 
anterior or posterior urethra. When the medicament is intended for the 
anterior urethra, the syringe may be introduced as far as the sinus of the 
bulb, and its contents ejected as the instrument is being slowly with- 
drawn (Fig. 20) . The liquid when applied to any portion of the anterior 
urethra will naturally escape from the meatus, but should be retained by 
compressing the lips of the meatus for a period of about one minute. When 
the application is made to the membranous or prostatic portions of the 
canal, it does not escape upon withdrawal of the instrument, but is retained 
by the compressor urethrse muscle. To reach the membranous urethra the 
syringe is passed into the sinus of the bulb and the tip of the instrument, 
by gentle pressure, is made to penetrate just inside the triangular liga- 
ment (Fig. 21). Eor the prostatic portion it is introduced by downward 
pressure about three-quarters of an inch farther. Twenty-five to thirty 
minims of liquid, which is the regular capacity of the Keyes syringe, 
are generally injected with each instillation. Larger quantities of mild 
solutions may be introduced by having a syringe with larger barrel 




Fig. 19.— Guyon's Syringe. 

(3i.-3iss.), but when a very strong solution of silver nitrate is em- 
ployed much smaller quantities are required, sometimes only a few 
drops. The bladder should be emptied prior to making an instillation to 
the posterior urethra, that the neck of the bladder may be also bathed 
with the injected fluid. 



CHRONIC URETHRITIS. 



47 



Of the various agents employed for urethral instillation the following 
are selected as being worthy of special notice : sulphate of thallin, sul- 
phate of copper, nitrate of silver, protargol, ichthyol. 

The sulphate of thallin is mildly astringent, antiseptic, and in weak 
solutions somewhat sedative in its action. It has been used in two- to 
two-and-oue-half-per-cent solution as an anterior injection in gonorrhoea, 
but its employment for this purpose has been practically abandoned. As 
an instillation to the posterior urethra in solutions of three to twelve per 




Fig. 30.— Anterior Urethral Instillation. 



cent, its most favorable effect is produced, which in some instances is 
strikingly satisfactory. 

In mild cases of posterior urethritis in which the discharge is slight 
and mucoid in character, when the deep urethra is hypersesthetic, stands 
instrumental interference poorly, and is irritated by the use of other 
applications, the sulphate of thallin will often prove of decided value. 
Neuralgic pains, which radiate through the posterior urethra, possibly 
induced by congestion remaining after the subsidence of a more active 
condition, will sometimes yield to it. Being about the mildest of all the 
deep urethral instillations, it is also used to lead up to the stronger appli- 
cations when they are not at first well tolerated. 

This preparation may be conveniently kept on hand in a twelve-per- 
cent solution, and diluted for use to the desired strength. It should be 
dispensed in a dark-colored bottle to prevent exposure to the light. The 
beneficial effect of this remedy is generally obtained by the use of a solu- 



48 



VENEREAL DISEASES. 



tion of from four to twelve per cent. The quantity injected at each sit- 
ting may be from Til xxx. to cxx. It is seldom irritating, and the urgent 
desire to urinate experienced in some instances after its use will quickly 
subside. It is on the whole an excellent agent for extremely sensitive 
urethras, and will often subdue a hypersesthetic condition when its use 
is persisted in. 

The sulphate of copper is markedly astringent, much more so than the 
sulphate of thallin. It is somewhat more irritating than this latter sub- 
stance, although it burns but little in weak solutions. It is also more 




Fig, 31.— Posterior Urethral Instillation. 



suited to the posterior than the anterior urethra. When the posterior 
urethra as a result of local congestion or mild catarrhal inflammation is 
found to be hypersemic and irritable, such a condition as is usually bene- 
fited by the use of astringent applications, a solution of sulphate of copper 
in increasing strength may be employed before proceeding to the use 
of nitrate of silver or after the effect of thallin has been exhausted. 
It may be conveniently kept on hand in a ten-per-cent glycerin solution, 
which will not precipitate, and the desired strength can be obtained by 
the addition of water. One grain to the ounce will be found very mild, 
and the full effect is generally obtained when the strength has been in- 
creased up to five or ten grains to the ounce. 

The nitrate of silver is probably more often used for instillation thau 



CHRONIC URETHRITIS. 49 

any other substance, and is of great value. It is stronger than any of 
the previous applications, and even when employed in weak solutions 
exerts a mild caustic influence, which is a desirable property for granular 
conditions of the mucous membrane. The general indications for the 
use of thallin and sulphate of copper apply to nitrate of silver, but al- 
though it is more irritating than either of the others, yet it is sometimes 
better tolerated and more beneficial even to sensitive subjects. Further- 
more it has a wider field of utility than either of them, being used also 
in the anterior urethra with good effect, on account of its bactericidal 
action. In that form of chronic urethritis which is a direct prolongation 
of recent acute trouble, in which the permanganate of potassium has been 
tried and found ineffective, or when this latter remedy has been used and 
under its influence the improvement has reached a stationary period, the 
substitution of a mild solution of silver may prove of decided value. 
Again, when the acute process of a recent urethritis has found its way to 
the posterior urethra and has become located there, its use will sometimes 
assist in terminating a condition which had promised to be of long dura- 
tion. In these latter cases, when well tolerated, it should be used in 
solutions of progressively increasing strength, beginning with gr. ss. and 
running up to about gr. x. to the ounce. 

Protargol. — This substance, which has already been referred to in the 
consideration of acute urethritis (p. 33), was invented by Eichengrtin, 
and brought to the public notice by Neisser, who, together with others 
who have experimented with it, have more particularly called attention 
to its value in acute gonorrhoeal urethritis. Later reports by Nogues' 
and Desnos'' have given an account of their experience with this remedy 
in the treatment of chronic urethritis, the results of which Desnos thinks 
show that it has greater value in the chronic than in the acute condition. 
We agree with him that it is inferior to permanganate of potassium irri- 
gations for gonorrhoea, and believe that its place as a topical application 
to the urethra belongs among the preparations used for posterior urethral 
instillation. 

Protargol is a proteid silver salt, readily soluble in water, and pos- 
sesses much less irritating properties than the nitrate of silver, although 
in solutions stronger than three to four per cent it is apt to excite an 
intense desire to urinate when deposited in the posterior urethra. 

' A concentrated solution of protargol makes a somewhat viscid and 
heavy mixture, and therefore should be used in a syringe with not too 
small a lumenand with a capacity of from 3 iss. to 3 ii., as this quantity 
is the amount usually injected with each application. 

In the anterior urethra protargol has been used in solutions of one- 
fourth to one per cent, but such mild solutions are of no value in the 

1 Ann. des Mai. des Org. Genito-Urin, , June, 1898. -^ Ihid., July, 1898. 

4 



50 VENEREAL DISEASES. 

posterior canal. Desnos recommends it in five- to ten-per-cent solutions, 
and has used it as high as fifteen per cent in chronic urethritis. Its best 
effect is to be obtained from strong solutions in chronic conditions. We 
have frequently used it in twenty- and twenty-five-per-cent solutions, and 
have increased it as high as forty per cent. Such strong solutions are 
best prepared before each application, and occasion a most intense desire 
to urinate, sometimes irresistible, and may produce marked symptoms of 
irritation, which endure for one or two days in many cases, while in some 
the amount of irritation does not seem to increase relatively with the in- 
creased strength of the solutions. Generally speaking, when such strong 
solutions are well borne, they are likely to produce good results. 

The subsequent applications should be at intervals of about forty-eight 
hours, or even longer, according to the irritation produced, which should 
be allowed to subside before repeating the treatment. 

When improvement is not noted after a reasonable period under the 
local use of this remedy in increasing strength, it should be abandoned. 

In that form of chronic posterior urethritis following closely upon 
gonorrhoea, its use is sometimes attended with markedly good results, 
either in connection with the permanganate irrigation of the anterior 
urethra or after the latter remedy has been discontinued. In this condi- 
tion it is well to start with a solution of from three to five per cent, and 
gradually increase as improvement is noted. In other cases of chronic 
urethritis, of much longer standing, protargol may prove an effective 
remedy when the trouble is one that involves the mucosa alone, and in 
some instances success will attend its use when other agents have failed. 
It may also be employed when the more deep-seated tissues or glandular 
structures are affected, as an adjuvant to the other treatment adopted. 
In the treatment of stricture of the urethra by the passage of sounds, it 
may be used as a topical application to the inflamed mucosa, directly 
behind the stricture or more properly to a posterior urethral catarrh, 
which often coexists with stricture of the anterior canal; and again in 
chronic prostatitis, while it does not reach the substance of the gland, it 
may be beneficially applied to the surface inflammation, while the deeper^ 
structures are attacked by other means. ^ 

The use of protargol in weaker solutions, one-fourth to one per cent, 
for urethro-vesical lavage or irrigation has also been recommended, not- 
ably when the discharge is abundant or the urine richly purulent. This 
may be conducted in the same manner as employed with the permanga- 
nate of potassium, and in some cases with beneficial result. 

Ichthyol. — This preparation is lauded highly by some observers for its 
soothing and antiphlogistic properties in the urethra. Of its use in acute 
urethritis we have nothing to say. In the chronic form of this malady it 
cannot be recommended for the anterior urethra ; its results are not equal 
to those obtained from the other remedies already mentioned. In the 



CHRONIC URETHRITIS. 



51 



posterior urethra in some cases of a subacute and chronic character good 
results have been noted after other means had failed, and it is on this 
account that it is considered worthy of being retained in the list of im- 
portant topical applications. We find that in cases in which its favorable 
effect is produced, the strength of the solution can be beneficially increased 
beyond what has been usually recommended, up to fifteen or even twenty 
per cent. It is well, however, to commence with a solution of very mild 
strength, viz., 2 to 3 per cent. 

Topical Applications by Means of the Endoscope. 

Even those who are ardent advocates of the general employment of 
urethroscopy do not urge its use in the posterior urethra where its appli- 
cation is often painful and productive of hemorrhage. With the Ober- 




FiG. 22.— Straight Tube for Anterior Urethroscopy. (Oberlander-Nitze.) 

lander-Nitze urethroscope (see Fig. 14, page 40) the endoscopic tube is in- 
troduced by means of a jointed obturator (Figs. 22 and 23) . Those who are 
skilled in the employment of this method in the posterior urethra in favor- 
able cases are able to make ocular inspection of the prostatic and ejaculatory 
ducts, the caput gallinaginis, and colliculus seminalis. It is not denied that 
the use of the endoscopic tube in the posterior urethra, on account of the 
irritation produced, is contraindicated in acute or subacute posterior ure- 
thritis in tuberculous cases and in hypertrophy of the prostate, yet it is 
claimed that in sexual neuroses and in chronic posterior urethritis it will 
often be found ?aseful.^ Even admitting the truth of this claim, there is 




Fig. 23.— Jointed Obturator for Posterior Urethroscopy. 

nothing to show that the results obtained are in any way superior to 
those following the simpler and more practical methods already detailed 
for deep urethral medication. 

The therapeutic application of urethroscopy to the anterior urethra is 
much more practical and sometimes decidedly serviceable. It is not to 



' "Practical Urethroscopy," Wossidlo, New York Medical Record, September, 



1895. 



52 



VENEREAL DISEASES. 



be recommended as a routine method. The different endoscopic tubes 
and apparatus have already been referred to in speaking of the diagnosis of 





i 
I 

.q 



{3 



T 



EiG. 24.— Anterior Urethral Polypus. 

chronic urethritis (see page 39) . Any one of these instruments may be em- 
ployed for the purpose of obtaining an ocular view of a localized lesion in 
the anterior urethra, and of permitting a direct application to the surface 
of a diseased area for the removal of granulations, papillomata, or polypi. 
For the latter purpose maybe employed a small wire snare (Fig. 25), 



G.TIEMANNScCn. 
Fig. 26.— Wire Urethral Curette. 



the urethral forceps, or a small wire curette (Fig. 26). The topical 
applications may be made by means of a cotton swab twisted on an 
applicator. For this purpose the nitrate of silver is commonly used in a 



CHRONIC URETHRITIS. 



53 



solution of from gr. i. to gr. xxv. to the ounce. If the visual inspection 
is able to detect the presence of a small abscess in one of the follicles of 
the urethra, it may be incised through the 
endoscopic tube by means of a properly 
constructed knife, such as that of Koll- 
man (Fig. 27), and the sac of the follicle 
injected by means of a small intra-urethral 
syringe or pipette (Fig. 28 and Mg. 44, 
page 70). Such an abscess cavity may be 
washed out with a mild antiseptic solution, 
but it is best treated by the introduction of 
a few drops of the ethereal solution of per- 
oxide of hydrogen, which will cause a rapid 






i^ 



disintegration of the inflammatory tissue and complete closure of the 
cavity by contraction of the follicular sac. 

In concluding this subject we must repeat that this method should be 
restricted within the lines of special indications, and that its general 
usage is to be discouraged. Such a practice as the use of daily endo- 
scopic applications to the urethra is not only liable to produce undesirable 
results upon the urethra, but must gain for the physician the far from 
enviable reputation of being a potterer. 



CHAPTER III. 

BALANITIS AND POSTHITIS— HERPES PROGENITALIS— 

VENEREAL WARTS. 

Balanitis signifies inflammation of the surface of the glans penis, 
posthitis inflammation of the prepuce, generally of its internal mucous 
lining. As these two conditions often coexist, the term balano-posthitis 
is employed. A long foreskin with small orifice predisposes to this dis- 
order, and the irritation due to retained smegma, urethral discharge, or 
other irritating fluid acts as an exciting cause. This condition is a 
common complication of gonorrhoea. 

In a mild form it amounts only to a bright redness and moisture of the 
mucous membrane, surrounding the glans and foreskin with a certain 
amount of creamy secretion of sharp, offensive odor, and accompanied by 
a constant itching or burning of the parts. In a more advanced form the 
mucous surface may become covered with excoriations. The whole sub- 
stance of the prepuce may be swollen and reddened, even sufficiently 
inflamed if the preputial orifice be narrow to occasion inflammatory 
phimosis. The excoriations result from the loss of epithelium in irregular 
patches, but when the irritation persists they go on to form ulcerations 
superficial iict character, more rarely deep, simulating closely the appear- 
ance of chancroids. An irregular form of balanitis occurs, called* "cir- 
cinate, '^ which appears in concentric patches resembling ringworm of the 
skin, said to be due to a special organism and of venereal origin. 

Chronic balano-posthitis occurs in men past the middle age, -generally 
in those with a tight and pendulous foreskin. The inflammation is mild 
in character, and as it extends over a long period produces a great deal 
of thickening of the mucous surface of the prepuce, which, when re- 
tracted, is found to be covered with granular prominences or superficial 
excoriations. Sometimes the prepuce is so much thickened around the 
orifice that retraction is impossible. A continuation of this process results 
in contraction of the infiltrated layer of epithelial and submucous tissue 
that has been deposited and a corresponding decrease in the normal size 
of the glans penis. 

The complications of balano-posthitis are phimosis, paraphimosis, 
vegetations, lymphangitis, inguinal adenitis, gangrene. Phimosis is the 
direct result of inflammatory swelling. Paraphimosis is due to thicken- 

1 Taylor: "Venereal Diseases." Berdall and Battaile: La M^decine moderne, 
1891-1892, and Annal. des Malad. des Organes g^n.-urin., vol. viii., 1890. 



BALANITIS AND POSTHITIS. 55 

ing of a retracted foreskin. Lymphangitis wlien present is similar to 
that which occurs with chancroids of the penis (see p. ). Inguinal 
adenitis sometimes accompanies lymphangitis as a complication of balani- 
tis, and resembles the same condition occurring in connection with chan- 
croids. Vegetations or pointed condylomata sometimes complicate a 
balano-posthitis as a result of the same causes that produced the latter 
trouble. Gangrene of the constricted prepuce may result from excessive 
swelling of the parts, the sloughing of the tissue included in the con- 
stricted area entailing ultimate deformity due to cicatricial contraction. 
This complication is more apt to occur in debilitated and cachectic in- 
dividuals. 

The diagnosis of balanitis is simple in most cases, but it may be con- 
founded with herpes, chancroid, or gonorrhoea. When the inflammation 
runs high, and perhaps exulceration exists upon the foreskin, it is diffi- 
cult to distinguish balanitis from herpes. In the early stage the outline 
of herpetic vesicles may be recognized. 

Chancroid is more apt to be confounded with severe balanitis, com- 
plicated by deep ulcerations. The course of the inflammation is much 
more severe and rapid in chancroid. Lymphangitis and adenitis are 
quite common, while in simple balano-posthitis they are less apt to be 
present, except in poorly nourished and debilitated individuals. 

In subpreputial chancre or chancroid, when the foreskin does not pull 
back, the diagnosis remains doubtful until the preputial cavity can be in- 
spected or other signs clear up the doubt. When there is a copious flow of 
pus, if there be phimosis, balanitis may be mistaken for acute gonorrhoea. 
This question is settled by the examination of the discharge for the 
gonococcus, and by determining whether or not the flow exudes from the 
meatus or is derived from the cavity of the prepuce. 

Treatment. — When the prepuce can be retracted, mild balanitis may 
be speedily relieved by the exercise of cleanliness and the use of a mild 
disinfectant or astringent lotion. For this purpose may be used the 
following: 

I^ Acid, boric, . . . . . . . . . 3 ss. 

Zinc, sulphocarbolat. , . . . . . . . gr. i. 

Aquae, , . • 5 iv. 

I^ Zinc, sulphat., 

Thymol., . aa gr. i. 

Acid, boric, 3 i. 

Spirit, lavand. comp., • 3 ij. 

Aquae, ........ q.s. ad § iv. 

I^ Vini aromatic, . , . . . . . . 3 iv. 

Aquae, . . . . , . . . . • I i- 

M. 

I^ Liquor plumbi subacetatis, 3 i. 

Aquae, . . . . c ? iv. 



56 VENEREAL DISEASES. 

A piece of absorbent cotton or a strip of thin old cotton cloth, moist- 
ened m one of the above lotions, is laid around the glans and the prepuce 
pulled forward to its natural position. This prevents friction and absorbs 
the irritating discharge. Dressings should be repeated several times a 
day. Sometimes a dry dressing acts better than a moist one, especially 
when erosions or ulcerations exist. Under these circumstances the dis- 
charge should be frequently removed and the glans and prepuce carefully 
washed with a mild disinfectant solution (corrosive sublimate 1 : 6,000 or 
8,000) after which the parts should be dried with absorbent cotton and the 
surface dusted with bismuth, perhaps containing a little boric acid or calo- 
mel, or with eudoxin. The combination known as dolomol tar we have found 
a useful and unirritating dusting-powder. In chronic cases and when the 
ulcerations persist in spite of the soothing form of treatment, the applica- 
tion of a solation of nitrate of silver, gr. x.-xxx. to the ounce, by means 
of a camel's-hair brush may assist in bringing about a more rapid cure. 
When the prepuce cannot be retracted, its cul-de-sac must be cleansed 
thoroughly with hot water, and one of the above lotions by means of a 
duck-bill syringe (Fig. 11, page 36). This should be done frequently 
during the day, as often as the discharge reaccumulates. If the parts are 
generally swollen, a wet dressing of Thiersch's or mild sublimate solution 
should be employed in addition to the other measures. If by the adoption 
of such means improvement is deferred, or if the inflammation is so in- 
tense that sloughing of the prepuce be threatened, it is better to relieve 
tension by slitting up the dorsum of the foreskin. If upon exposure of 
the region behind the glans chancroid is discovered, its treatment should 
be conducted in accordance with the instructions laid down in the section 
on chancroidal phimosis (p. 186). In all chronic cases of balanitis with 
phimosis and thickening of the mucous membrane circumcision affords 
proper means of relief, and should be resorted to. Lotions and astringent 
injections in these cases afford little relief, as relapses are liable to recur 
continually. 

Herpes Progenitalis. 

Herpetic vesicles, single or multiple, appear upon the mucous mem- 
brane covering the glans and prepuce aud upon the cutaneous envelope 
of the penis. They may be located in the sulcus, behind the corona, in 
the folds of the frenum on either side, around or inside the meatus, or 
on any portion of the integument. When occurring upon the skin the 
vesicles dry down and form scabs, but when situated upon the mucous 
lining they run a different course owing to the rupture of the vesicle, 
which takes place early, leaving a more or less superficial exulceration. 
In the case of a single vesicle this is irregularly round, but when several 
vesicles lie close together they may become fused into a single patch of 



1 



HERPES PROGENITALIS. 57 

irregular outline. The symptoms attending this lesion are burning or 
itching of the surface implicated, and a certain amount of watery secre- 
tion, which, when allowed to collect, . becomes purulent. Subpreputial 
herpes, after the vesicles break, may run on into balano-posthitis if the 
secretion be allowed to accumulate. When the ulcerations become un- 
usually deep as the result of neglect of treatment or constitutional debil- 
ity, and are accompanied by inguinal adenitis, the sores may be con- 
founded with chancroidal ulceration. In reaching a diagnosis it should 
be remembered that the herpetic condition starts in vesicles, generally in 
clusters which precede the appearance of ulceration, and that bubo is 
uncommon. Differential diagnosis is sometimes difficult, but a decision 
may be promptly and surely reached by auto -inoculation. The pus of 
ulcerated herpes will not produce the typical ulcer which surely follows 
the auto-inoculation of chancroidal pus. The duration of herpes when 
uncomplicated is from three or four days to a fortnight. 

The causes of herpes are local irritation and diathetic predisposition. 
Uncleanliness, the decomposition of sebaceous material, especially when 
the prepuce is long and contracted, and the friction of intercourse may be 
cited. Full-blooded, gouty, rheumatic, and neurotic individuals seem to 
possess a predisposition to the affection. If, as has been held by one or 
two observers, it is of special microbic origin, sufficient evidence has not 
been produced to sustain the claim. Sometimes herpes progenitalis is 
attended by rather pronounced neuralgic pain — a feature which may be 
marked in any kind of herpes, reaching its highest expression in herpes 
zoster. This rather exceptional accompanying symptom has led a few 
authors to the extremity of erecting a new sub-variety of herpes, which 
they call neuralgic. 

Treatment. — For cutaneous herpes prevent the vesicles from breaking 
by covering the patch with collodion, and keep it covered until it is well. 
If the vesicles break, dust them with bismuth or eudoxin. On the mu- 
cous surface touch the vesicles twice daily with eucalyptol and dust with 
bismuth or eudoxin when they break. After excoriations occur the treat- 
ment is generally the same as for balanitis, requiring that the irritating 
discharge should be removed and the parts cleansed and maintained in this 
condition by suitable disinfectant lotions. As indicated in the previous 
section on balanitis, after using the lotion the parts should be thoroughly 
dried and a mild dusting-powder applied — bismuth, zinc, starch, and ly- 
copodium. The dolomel and tar or eudoxin will be found especially effi- 
cacious. Eudoxin is the bismuth salt of nosophen, the latter being a 
compound rich in iodine and an iodoform substitute. Underlying con- 
stitutional conditions should be attended to. In chronic and relapsing 
herpes, in cases accompanied by sharp neuralgic pains, and in those 
showing a tendency to persistent ulceration, it is necessary to alter the 
surface by a caustic, for which purpose may be employed carbolic acid. 



58 VENEREAL DISEASES. 

a ten-per-cent solution of nitrate of silver, or antiseptic pyrozone. 
When a long, tight prepuce is the predisposing cause, circumcision is 
the natural remedy. 

Venereal Warts. 

Vegetations, condylomata, or venereal warts, as they are commonly- 
called, spring up readily in both sexes about the genitals if acrid and 
irritating discharges be retained until they have had time to decompose. 
Pathologically they consist of highly vascular papillary outgrowths, com- 
posed of an increase of the epithelial and connective tissue. They are 
not necessarily of venereal origin, bat are common under a tight prepuce 
in connection with gonorrhoea, and often found complicating balanitis 
when there is no urethral inflammation. Those that occur upon the 
mucous membrane are soft and yielding in character ; upon the integu- 
ment they are harder. When dry they resemble ordinary seed warts, 
and are composed of pointed epithelial prominences which grow up into 
a raspberry-like mass, varying from the size of a pinhead to that of a 
hickory nut. They may spread out as a dry velvety growth over a large 
surface. The soft warts are commonly situated behind the corona glandis 
on either side of the frenum, but may be encountered on any portion of 
the mucous surface of the prepuce. They are sometimes found in the 
mouth of and deep in the urethra, and are distributed also over the scrotum 
and frequently around the anus. They may be scattered in irregular 
collections in one or more of these sites, or may be so abundantly gathered 
upon the glans penis as completely to bury it, giving a cauliflower-like 
appearance, with the glans almost hidden from view ; or if the prepuce 
be long, the extensive outgrowth may emerge through the orifice, or, on 
account of a tight phimosis and consequent subpreputial pressure, may 
produce gangrene and perforation of the prepuce. 

The inflammation due to these excrescences and their irritating dis- 
charge may result in a balano posthitis and inflammatory phimosis. 

Paraphimosis may also come on during a retraction of the prepuce on 
account of the hyperplastic inflammatory condition of the tissues due to 
their presence. 

The contagiousness of venereal warts has been maintained by some 
writers, but this question is still unsettled. 

The diagnosis of these growths is self-evident. They should not be 
confounded with "condylomata lata," which are of specific origin and 
generally accompanied by a clear syphilitic history. Such an error can 
be made only when the vegetations or warts have existed for a long time 
and have undergone changes which have resulted in their becoming more 
dense with pronounced flattening of the surfaces. Epithelioma at the 
beginning of its course may be mistaken for condylomata. The former ap- 
pears late in life and is accompanied by infiltration of the adjacent tissues 



VENEREAL WARTS. 59 

and enlargement of the nearest chain of glands. In a case of doubt, in 
which the suspicion has been raised, microscopic examination will decide. 

Treatment. — The prophylaxis against these warty excrescences is 
cleanliness, especially in the event of balanitis or gonorrhoea. When 
warts are encountered in cases in which the foreskin can be retracted, they 
may be removed with scissors and their bases cauterized with nitric 
acid or caustic pyrozone, having previously anaesthetized the surface 
with cocaine. When the growths cover an extensive area they may be 
thoroughly scraped away by means of a sharp curette and the denuded 
surface cauterized with acid and treated with a dry dusting-powder com- 
posed of calomel, oxide of zinc and bismuth, or eudoxin, the bismuth salt 
of nosophen, an iodine compound and an iodoform substitute. 

A most satisfactory way to treat these warts is to apply — 

I^ Acid, salicylic, gr. 1. 

Acid, acetic, ......... ^i. 

This combination forms a curd-like mixture which generally will remove 
warts of all sizes upon the foreskin and prepuce, leaving a smooth surface 
within twelve or twenty-four hours. In using this preparation a suffi- 
cient quantity of the dregs of the mixture should be deposited upon the 
growths to cover their entire surface, and be allowed to dry. One appli- 
cation is generally sufficient. 

When vegetations occur within a phimosed foreskin, it may be neces- 
sary to slit or cut away the latter^ 

Phimosis, Paraphimosis, Circumcision. — Phimosis is said to exist when 
the orifice of the prepuce is too small to allow the glans penis to be un- 
covered. It may occur congenitally, but is also acquired as a complica- 
tion during an attack of balano-posthitis, either alone or in combination 
with the presence of herpes, vegetations, or chancroid. 

This condition exists in various degrees as a congenital formation, 
producing a contracted orifice, which may simply prevent retraction of 
the foreskin or may be so tight as to impede the flow of urine. Such an 
extreme condition will naturally favor the occurrence of balanitis, and 
interfere with the proper treatment of the morbid conditions which attack 
the interior of the prepuce. 

Inflammatory j^himosis is a transient trouble due to inflammation of 
the prepuce. It may leave behind a true phimosis as a result of chronic 
thickening. The treatment of inflammatory phimosis consists in treating 
the cause which underlies it ; in addition evaporating lotions in the form 
of wet dressing may be applied, while the cavity of the prepuce is kept 
continually washed with an antiseptic solution composed of carbolic acid, 
1:50, or corrosive sublimate, 1 : 5,000. It is better not to incise an 
inflammatory phimosis unless the condition inside the prepuce demands 
it. When such is the case the operation should be performed by making 



60 



VENEREAL DISEASES. 



two lateral incisions, and completing tlie circumcision when the inflam- 
matory condition and local lesions have yielded to treatment. 




Fig. 29. 



Paraphimosis is the condition which exists when the prepuce gets 
behind the corona glandis and cannot be replaced. Occurring with gonor- 
rhoea it is caused by oedema of the retracted foreskin. Such inflamma- 
tory paraphimosis may depend 
also upon balanitis, herpes, 
chancroid, or chancre. The 
glans penis in paraphimosis is 
swollen and livid. When seen 
early there may be little in- 
flammation of the glans or pre- 
puce, but when the condition 
continues and is unrelieved, 
inflammation may reach a high 
degree, oedema of the prepuce 
becomes very extensive, the con- 
stricting portion behind the 
corona appears like a cartilagi- 
nous ring, and the glans penis 
may even become gangrenous 
from strangulation. 

Sometimes, although the 
foreskin is not long enough to 
cover the glans, oedema may oc- 
cur, giving the same appearance 
as in the case of paraphimosis 
with contracted and long pre- 
puce. Under these circumstances the deeper parts are not strangulated, 
and there is no occasion to attempt reduction. 




Fig. 30. 



VENEREAL. WARTS. 



61 



The treatment of paraphimosis varies with the presence or absence of 
strangulation. When there is no strangulation, the indication is to 
endeavor to allay the inflammation by the use of wet dressings or fomen- 
tations. In some mild cases the application of a few coats of contractile 




Fig. 31. 

collodion over the smooth mucous membrane will control the tendency to 
increasing oedema and may cause its disappearance. Should positive 
strangulation of the penis occur, as evidenced by the bluish-black color of 
the glans, which becomes turgid and swollen, cold and devoid of sensibility, 
reduction of the strangulation is imperative. This may be done in several 
ways. One way is to en- 



circle the penis with one 
hand (Figs. 29 and 30), or 
with the thumb and index 
finger of one hand, using 
the other one to knead and 
compress the glans and 
push it back through the 
constricted ring of the 
prepuce. Another is to 
grasp the penis behind 
the constricted portion be- 
tween the index and middle fingers of both hands, making pressure with 
the thumbs on either side of the glans and at the same time pulling 
the strictured prepuce forward, the purpose being to make the glans as 
small as possible and to draw the constriction over it rather than to push 
the glans through the stricture (Fig. 31). Still another method is to com- 
press the swollen glans by means of a one-half -inch muslin or rubber 




Fig. 32. 



62 



VENEREAL DISEASES. 



bandage, applying it from apex to base, and then endeavor to retract the 
prepuce forward with the bandage in place by one of the manipulations, 
or to remove the bandage and immediately attempt reduction before the 
engorgement has had time to return to the same extent (Fig. 32). Finally 
by means of the introduction of hair-pins, one on either side of the glans, 
beneath the constriction, to act as directors, success may be accomplished 
when the other methods have failed (Fig. 33). When the prolonged and 
careful attempts at reduction fail, the stricture behind must be divided 




FIG. 33. 

with the knife. To accomplish this a blunt tenotomy knife is introduced 
on its flat surface beneath the stricture, and is made to cut outward, or 
the incision may be made directly down upon the sheath of the penis. 
Sometimes the inflammatory infiltration of the tissues necessitates the 
division of the stricture at several points. 

Circumcision. — To expose the glans penis it is sufficient to make one 
long incision upon the dorsum of the prepuce, including both layers, from 
the orifice to the base of the corona, and after trimming off the corners 
to unite the two layers on either side. When the prepuce is very tight, 
a grooved director may be passed from the orifice to the corona, in the 
middle line. A short, pointed bistoury is then run along the groove, 
which transfixes the skin and incises the entire prepuce. This operation 



VENEREAL WARTS. 



63 



leaves two clumsy dog's ear flaps, but is much simpler than complete cir- 
cumcision. Taylor strongly recommends instead of the dorsal incision 
that two lateral cuts be made, and contends that the dorsal incision is 




Fig. 34.— Authors' Phimosis Olamp. 

unsatisfactory in that it does not always produce the desired relief and 
renders the parts less accessible than by the lateral cuts. 

Circumcision proper is a simple operation which is performed for the 
purpose of removing the orifice of a tight prepuce and all redundant tis- 
sue. The operation is as follows : Wash the outside of the foreskin, and. 




Fig. 35.— Circumcision I. Showing aniline line to mark incision. 

if possible, the inside as well. In children general anaesthesia should 
be employed. In adults local cocaine or eucaine anaesthesia suffices un- 
less the operation is to be complicated and prolonged. The prepuce is 
caught at its orifice and drawn forward, not rolled upon itself, and a 
clamp applied in an oblique direction — that is to say, the general direc- 



64 



VENEREAL. DISEASES. 



tion of the corona — at the point corresponding to a line previously drawn 
on the integument parallel to and somewhat in front of the corona, while 
the foreskin was in its normal position. The cavity of the prepuce 
should be injected full of an eight- or ten-per-cent solution of cocaine, 
which should be retained for at least five minutes. The line of the incis- 
ion through the integument can be completely anaesthetized by infiltration 
with cocaine. For this purpose a two-per-cent solution is used, after 
which, if one wishes a neat operation, the base of the penis may be con- 
stricted with a rubber tube or catheter, the ends of which are fastened in 
place by a bit of tape or a haemostatic forceps. As the relation of the 




Fig. 36.— Circumcision II. Showing clamp applied to foreskin. 



^parts is somewhat disturbed by these preliminary steps, it is a good plan 
to mark the line of the incision upon the integument with an aniline 
pencil before doing anything else (Fig. 35). The phimosis clamp is now 
applied and with a sharp bistoury or scissors the prepuce is cut away be- 
yond the blades (Fig. 36) . After removal of the forceps retraction of the 
integument occurs, and the mucous membrane is left, covering the glans 
(Fig. 37). This should be slit down upon the dorsum or laterally (Fig. 38) 
about one-quarter inch from the corona, peeled or dissected from the glans 
if there be adhesions, and trimmed away on either side, leaving about one- 
fourth of an inch to hold the sutures. As many bleeding points as can 
be controlled by torsion should be treated in this way, and ligatures ap- 
plied only where necessary. Blood clots should be scratched away with 
the nail and any little oozing vessel twisted. If in spite of the oval opening 
of the oblique incision the newly made orifice appears too tight, a liber- 



VENEREAL. WARTS. 



65 



ating incision should be made down the back of the penis for one-fourth 
of an inch. The mucous membrane must be liberated so as to leave the 




Fig. 37.— Circumcision III. After removal of clamp. 

entire corona clean. The best material for ligature is rather coarse 
horse-hair. Catgut is not suitable. It makes a large suture hole, and is 
liable to give way during erection. It is better than silk because it does 




Fig. 38,— Circumcision IV. Showing mucous membrane after lateral incision and before it Is trimmed. 

5 



66 



VENEREAL DISEASES. 



not have to be removed, but horse-hair, if properly placed very close to 
the margin of the integument and of the mucous membrane, does not 
have to be taken out, as in the course of a few days, if the first knot be 
tied tightly, it always cuts through the suture hole and comes away with 
the little brown serous scab, leaving a perfect line of union. Erections 
make no difference in the healing if the dorsal slit is made. This leaves 
a loose suture line. As many as twenty or twenty -five sutures may be 
applied, the first one being placed at the raphe and the second one in the 
centre of the dorsum, and then as many more on either side between these 
points as may be necessary to obtain close apposition of the wound sur- 
faces. To prevent the horse-hair ends from turning in and their points 




Fig. 39.— Circumcision V. Operation completed. Horse-hair sutures. 



irritating the glans (since in many cases a little oedema occurs causing 
the suture line to roll inward), the ends of the hairs should be left about 
one inch long (Fig. 39). After forty-eight hours they should all be 
trimmed down close to the serous scab, which will have formed. When 
the scab falls spontaneously, the sutures will come away unnoticed in it, 
leaving a dry line of union. In children this is a valuable feature of the 
operation, because the little patients do not like to have the wound dressed 
or touched in any way. The operation being completed the parts are 
washed, and the line of incision is dusted with a little astringent antiseptic 
powder, such as nosophen or aristol. No bandage or dressing of any 
kind is required. It is hard to keep in place, only irritates, and is abso- 
lutely unnecessary. A contrivance in the shape of a circular roll, made 



VENEREAL WARTS. 



67 



of an ordinary towel, should be placed about the penis, that the member 
may lie sideways against it. This is to be tied to the body with four 
tapes, one around each thigh and two to a waistband, for the purpose of 




Fig. 40, 



keeping the bed-clothes from contact with the penis (Fig. 40). It is a 
most exceptional occurrence in simple cases not to obtain complete union, 
but if from any cause a granulating surface is left, it should be treated 
with a dusting -powder or stimulating applications. 



CHAPTER IV. 

INFLAMMATION OF URETHEAL FOLLICLES — PEEI - URE- 
THEAL ABSCESS — COWPEEITIS — PROSTATITIS — SEMI- 
NAL VESICULITIS. 

The common complications of urethritis beyond those already con- 
sidered — chordee, balanitis, etc. — consist of inflammation of the glands 
of the urethra, folliculitis, peri-urethritis, cystitis, prostatitis, and epi- 
didymitis, which occur in connection with the chronic as well as the acute 
form of the disease. 

Inflammation of the Urethral Follicles. — The follicles of the urethra 
always participate more or less in all acute inflammations of the canal. 






Fig. 41.— Follicular Abscess Complicating Urethritis in Different Locations. 

In chordee the follicles at the affected spot are certainly involved, and 
may be the route by which the inflammation reaches the deeper tissues. 
These mild inflammations get well spontaneously, as a rule, when the 
surface congestion goes down. 

The cause of follicular inflammation of the urethra is found in some 
form of local irritation to the already congested canal or during an attack 
of urethritis, such as irritating injections, frequent erections, nocturnal 
emissions, etc. When a single follicle or a group of follicles is attacked 
by an extension of inflammation, each one may be felt imder the skin, 
generally on the floor of the urethra, like a small shot or pea. When 



INFLAMMATION OF URETHRAL FOLLICLES. 



69 




the follicular mouth becomes closed during the course of such an inflam- 
mation, an abscess is formed in the dilated sac of the follicle, which event- 
ually discharges itself externally through the skin, or internally through 
the natural duct of the follicle (Fig. 41). When 
an external opening occurs, urethral fistula 
may be the ultimate result. A favorite site 
of these follicular abscesses is behind the 
meatus in the fossa navicularis, on one or 
both sides of the frenum. The inflammation, 
if unabated, may extend from these follicles 
into the cellular tissue, peri-urethral inflam- 
mation (Fig. 42). When a cellular inflamma- 
tion occurs, the outline of the follicle is gen- 
erally lost, a phlegmon is formed which is not 
likely to undergo resolution, but discharges 
itself either externally or internally, or both. 
In the latter instance, as in the case of a fol- 
licular abscess, a urethral fistula may result. 

Treatment. — At the onset the treatment 
of follicular and peri-urethral inflammation 
should be antiphlogistic — rest, freedom from 
all local irritation, and mild antiseptics, if any 
local measures be adopted. Irritating injec- 
tions should be positively avoided. If irri- 
gations of permanganate of potassium are being 
used, they may be continued under light pres- 
sure in mild strength (1 : 6000) . The external application of ten to twenty 

per cent of ichthyol oint- 
ment is sometimes useful. 

When suppuration occurs 
and the abscess points ex- 
ternally, an incision through 
the skin should be made to 
evacuate the pus, except 
when the follicular abscess 
presents near the meatus 
and can be reached from 
the interior (Fig. 43). In 
this instance an internal in- 
cision should be made and 
the abscess treated on the 
inside, thereby often pre- 
venting the formation of a 
Fig. 43.— Follicular Abscess in the Fossa Navicularis. , •■ -i r» i -i 

Preparation for incision through meatus. uretnrai u StUia. 



Fig. 43.— Peri-Urethral Abscess 
Involving Follicles on the Floor 
of the Urethra. 




70 



VENEREAL DISEASES. 



A most satisfactory mode of treating these abscesses after they have 
discharged, whether externally or internally, is by the injection into the 
cavity of a small quantity of the ethereal solution of peroxide of hydrogen 
(pyrozone), commencing with twenty -five-per-cent (caustic) solution so 
as to destroy the unhealthy tissue and continuing with the same strength, 
or with the weaker five-per-cent (antiseptic) solution at intervals of one 
or two days between each application. By this method a rapid contrac- 
tion and closure of the sac is produced and the danger of fistula may be 
avoided. These solutions are applied by means of a pipette, which is 
drawn to a very fine point (Fig. 44). 

Other methods of treating these abscesses are based upon general sur- 
gical principles of antisepsis and drainage, which require that after the 




Fig. 44.— Treatment of Follicular Abscess from Interior. 



abscess is opened it should be washed at regular intervals with antisep- 
tic solution, and made to heal from the bottom by packing with gauze. 

Inflammation of Cowper's Glands. — This is another form of follicular 
inflammation of the urethra which occurs in the glands of the bulbous 
portion known as Cowper's glands, cowperitis and peri-cowperitis. The 
causes are much the same as in follicular inflammation in other portions 
of the urethra, some kind of direct local irritation or traumatism during 
an attack of urethritis, generally gonorrhoeal. 

The primary symptom of this complication is pain in the perineal 
region, which when occurring during the acute stage of urethritis should 
always suggest the possibility of inflammation in one of these glands. 
Examination reveals a painful and indurated swelling in the perineum, 
corresponding to the locality of Cowper^s glands, generally on one side 
only. It is important to recognize this condition at its onset, as in the 
majority of instances, when discovered early enough, resolution may be 



INFLAMMATION OF COWPER's GLANDS. 



71 



brought about by antiphlogistic measures. When this latter course is 
not taken, suppuration occurs, characterized by the enlargement of the 
swelling in a more or less oval shape, somewhat pointed toward the anal 
region. The swelling later diffuses itself into the surrounding tissues, 
pericowperitis, and extends forward in front of the scrotum (Fig. 45) . The 
surface of the skin reddens, the tumor softens, 
having in some cases reached the size of a 
hen's egg. 

When suppuration occurs, the abscess 
may open both into the urethra and through 
the perineum, and is liable to leave urethro- 
perineal fistula. More often, however, the 
tumor resolves without suppuration, especial- 
ly if recognized early and properly treated. 

Certain cases that have suppurated and 
discharged in one or both directions, notably 
if not well treated or if the general health 
be undermined, terminate in chronic cow- 
peritis with internal or external fistula, or 
both, a very obstinate and annoying malady. 
If there be complete urethro-perineal fistula 
it may permit leakage during urination, or 
the size of the fistula may be too small to 
allow the passage of a visible quantity of 
urine and be only demonstrable by injection. 

There are no symptoms peculiar to cow- 
peritis beyond those of pain, swelling, in- 
duration, and suppuration corresponding to 
the anatomical situation of Cowper's glands, 
occurring during the course of acute ure- 
thritis. The diagnosis therefore based upon these symptoms is not diffi- 
cult. When recognized early it should not be confounded with perineal 
inflammation or urinary infiltration. Its location should differentiate it. 
When there is a general peri-cowperitis its recognition is more difficult, 
and a distinction between it and urinary infiltration from the urethra 
may be troublesome, but the latter is usually a result of tight stricture or 
of old chronic inflammation of long standing. 

While malignant disease and tubercle do occur in this region, they 
have been very seldom observed. In distinguishing either one of these 
conditions it should be borne in mind that the course and duration of 
acute cowperitis are rapid and short, generally not lasting over five or six 
days, while both tubercle and cancer are essentially chronic in character. 
Generally speaking, a chronic cowperitis which persistently resists treat- 
ment should lead to the supposition of the existence of underlying tuber- 




FiG. 45.— Cowperitis. Peri -ure- 
thral abscess beginning in Cowper's 
glands and extending to the peno- 
scrotal angle. 



72 VENEREAL DISEASES. 

cle, and calls for careful bacteriological examination of the pus and 
fistulous scrapings. 

Treatment, — As already stated, it is most important to recognize cow- 
peritis at its inception, during which period antiphlogistic measures are 
indicated, poultices, baths, and if the inflammation be sufficiently intense, 
the application of leeches to the perineum. Absolute rest should be en- 
joined and all direct urethral applications discontinued. As soon as sup- 
puration becomes evident it is necessary to evacuate the pus, and for this 
purpose a free incision should be made over the most prominent point of 
the swelling. The abscess should be washed out with an antiseptic solu- 
tion and the cavity packed lightly with gauze, for the purpose of en- 
couraging rapid contraction and healing from the bottom toward the sur- 
face. As soon as cicatrization commences, and even before the cavity 
has contracted completely, the same method suggested for the treatment 
of follicular abscess of the urethra is to be recommended here — namely, 
the injection of the ethereal solutions of peroxide of hydrogen (pyrozone), 
at first every day and later every second or third day, in the hope of 
causing a complete closure of the fistulous tract. At the beginning of 
this treatment, when the surface to be treated is large, it is well to begin 
with the five-per-cent solution of this preparation, and when the cavity has 
contracted down to a fistulous canal the twenty-five-per-cent caustic solu- 
tion may be resorted to with good effect. In many instances this treatment 
may result in the complete closure of the fistula. When these means fail, 
the alternative is the complete extirpation of the fistulous tract and of the 
indurated mass of glandular tissue^ 

Acute and Chronic Prostatitis. 

Prostatitis, — Etiology : Acute prostatitis is quite often a complication 
of gonorrhoea, but it also attends non-specific urethritis, notably when 
stricture is present, and it may occur in connection with sexual strain, 
masturbation, pre-existent prostatic disease, tubercle, cancer, or from 
traumatism. 

The rheumatic, scrofulous, and tuberculous diatheses are predisposing 
causes, while sexual excitement, alcoholic excess, over-exercise, and 
traumatism — especially instrumental — during an attack of urethritis, 
may be the determining factors in its production. 

Follicular Prostatitis. — Mild prostatitis is a common complication of 
acute urethritis after it has invaded the posterior urethra. Confined mostly 
to the surface and to the follicles of this portion of the urethra, it is not, 
when properly treated, of long duration. The prostatic urethra becomes 
congested and swollen. Granulations may form on the surface of the 
mucous membrane. The superficial follicles of the prostate may become 
engorged, and their mouths dilated with contained pus, which may ex- 
ude and give rise to a purulent discharge. 



ACUTE AND CHRONIC PROSTATITIS. 73 

The symptoms consist of a somewhat urgent and frequent desire to 
urinate, which varies more or less according to the intensity of the in- 
flammation. The desire to urinate may persist after the bladder has 
been emptied, and there is likely to be pain at the end of the urinary act. 
The coexistence of a certain amount of urethro-cystitis or inflammation 
of the neck of the bladder is more than likely. The above symptoms 
resemble closely those of the latter disorder. Besides the presence of a 
certain amount of urethral discharge, the urine is purulent and the pres- 
ence of pus from the posterior urethra may be demonstrated by washing 
out the forward canal before the urine is voided. Sometimes a few drops 
of blood trickle away after the urinary act. 

Parenchymatous Prostatitis. — The foregoing description refers to a 
mild type of prostatitis. A higher grade of the malady involves the 
parenchyma of the organ, and may or may not result in prostatic abscess 
and periprostatitis. 

When prostatitis attacks the body of the gland, the latter becomes 
increased several times its normal size; its consistence is firm and resist- 
ant; the tissues are engorged with blood and distended with an exuda- 
tion which is at first serous and later of a purulent character. Sometimes 
one half of the gland is more enlarged than the other, and sometimes 
lumps and nodes are felt upon the surface on account of irregular distri- 
bution of the inflammatory process. The gland throbs when palpated by 
rectal touch. 

Abscess of the prostate occurs as a result of the formation of multiple 
pus foci, which are distributed throughout the glandular structure and 
later unite into one pus sac of variable size, which is generally located in 
the posterior portion of the lateral lobes. More rarely small hemorrhagic 
infarctions occur in the gland, varying in size from a small pearl to that 
of a pea, which become the point of departure of the prostatic abscess 
(Desnos). 

In the early stage these small pus collections are separated by thick 
and resisting walls. Sometimes they are seated beneath the urethral 
mucous membrane and more rarely beneath the mucous membrane of the 
rectum. Later the dividing walls give way and the small sacs communi- 
cate with each other. The accumulated pus is gelatinous and thick. 
Generally the ejaculatory ducts become thickened and filled with pus and 
the seminal vesicles may also suppurate — acute vesiculitis. 

When the abscess perforates in the direction of the urethra the result- 
ing cavity fills up more or less slowly, according to the rapidity of the 
healing process. Sometimes it remains for a long period and becomes 
the site of a chronic prostatitis connecting with the urethra. At other 
times the abscess evacuates by way of the rectum or departs in different 
directions through the enveloping fascia, in which case a periprostatic 
abscess is formed which involves inflammation of the recto-vesical space. 



74 VENEREAL DISEASES. 

Periprostatic abscess may arise from other causes, wounds or lacera- 
tion of the rectum, from inflammation of the bladder or seminal vesicles, 
but most commonly it is propagated from the prostate gland. The 
extension of inflammation takes place through the venous and lymphatic 
vessels or is diffused through the cellular tissue (Guyon). 

A phlegmon located in this region varies in its size and activity 
according to the cause and nature of its production. When it is diffused 
through the cellular tissue the cavity may become limited and remain for 
a long time. When it is propagated through a lymphangitis or phlebitis 
it is apt to be more extensive and of more serious import. The abscess 
is not formed by the combination of several smaller foci, but is generally 
one separate cavity. A notable feature is that the neighboring organs 
are not of necessity greatly influenced by the proximity of this inflamma- 
tion. It is possible to have extensive periprostatic suppuration accom- 
panied by a relatively small amount of functional disturbance. On the 
other hand, the neighboring organs may be affected and may participate 
in the inflammatory process. Sometimes a large cavity communicating 
with the bladder or a fistulous tract in the rectum may remain after 
evacuation of the abscess. At other times recto-urethral fistula is the 
result. 

Symptoms and Course. — In follicular prostatitis complicating acute or 
chronic urethritis, the symptoms, as stated, vary in intensity with the 
grade of the inflammation and consist of more or less urgent desire to 
urinate, and a sense of itching or discomfort in the perineal region. The 
desire to urinate, however, is not uncontrollable, and the intervals between 
the calls may be nearly normal unless there coexists inflammation of the 
neck of the bladder. 

In severe cases pain in the prostatic region persists after the bladder 
has been emptied, and the flow of urine is followed by the passage of 
several drops of blood. The first flow of urine always contains- a certain 
amount of pus, derived from the prostatic sinus or from the suppurating 
follicles. 

Acute prostatitis, involving at once the whole gland, is sharp in its on- 
set, sometimes preceded by a chill and accompanied by marked pyrexia. 
Attention is immediately attracted to the prostate by the pain in the 
perineal region, attended by a dragging or bearing-down sensation. 
These symptoms often supervene after the unwise or careless use of 
instruments in the posterior urethra. When the symptoms run high, the 
possibility of prostatic abscess should be borne in mind. The pain upon 
urination becomes intense, the few drops of urine remaining in the blad- 
der causing frequent and violent vesical spasm. Between the paroxysms 
the calls to urinate are not imperative, as is the case in cystitis. 

Pain in the rectum is also complained of ; defecation intensities it and 
provokes vesical and rectal spasm. If the prostate be examined by the 



ACUTE AND CHKONIC PROSTATITIS. 75 

rectum, it is found to be hot, swollen, throbbing, and intensely painful. 
The enlargement may be symmetrical or confined to one lateral half. 
Such examination may excite in the patient an irresistible impulse to 
evacuate both the bowel and the bladder. 

Suppuration ©ccurring in the substance of the prostate gland during 
an attack of acute prostatitis is marked by rigors and chills, increase in 
the fever, and general malaise. The local symptoms become aggravated, 
the sensitiveness being so great that every movement of the body intensi- 
fies the pain. Defecation is rendered almost unbearable. All of these 
intense symptoms cease almost instantly after the evacuation of the pus 
when the malady takes this favorable turn, which is generally the case. 
Sometimes, however, general sepsis comes on, the chills continue, the 
temperature mounts, and the indications point toward general systemic 
infection. This unfavorable course is of grave import and menaces life. 

Prostatic abscess generally breaks toward the urethra. Rupture 
usually occurs spontaneously during straining at stool or the spasmodic 
efforts attendant upon urination. When the evacuation of pus is com- 
plete, recovery is progressive; but when the evacuation is incomplete, all 
the foci not being freely drained, grave complications are to be feared — 
septicaemia, infiltration of urine. Eecovery may also be retarded by the 
too rapid closure of the opening, causing the pus to burrow in other 
directions and leading to the formation of multiple openings (Desnos). 
Not infrequently the pus burrows toward the rectum, and either dis- 
charges directly into the bowel or more commonly diffuses itself into the 
cellular tissue between the prostate and the rectum — periprostatic ahscess. 
When this complication ensues, rectal examination detects the general 
diffusion of the inflammatory thickening, blotting out the limits of the 
prostate gland. Laterally the tissues surrounding the prostate effec- 
tually limit the course of the pus, but below the resistance is less and 
there the pus diffuses itself and may open into the urethra, the rectum, 
the ischio-rectal fossa, or the perineum. The double opening into urethra 
and rectum is common, yielding urethro-rectal fistula. 

Diagnosis. — Follicular prostatitis occurring during an attack of gonor- 
rhoea is recognized by an increased urgency and frequency of urination, 
the occurrence of pus in both flows of the urine, and usually by a 
coincident cessation of purulent discharge from the meatus. These 
symptoms, however, also occur in cystitis, and these two conditions are 
likely to coexist — hence the term urethro-cystitis (page 89). 

When inflammation attacks the body of the gland, most of the sub- 
jective phenomena are intensified, and marked constitutional symptoms 
appear, chills, rigors, pyrexia, etc., notably when suppuration occurs. 
Unless the vesical neck be also implicated, there may be little or no fre- 
quency of the urinary call. Rectal examination will detect a hard, pain- 
ful tumor of unequal proportions, and sometimes a fluctuating point. 



76 



VENEREAL DISEASES. 



Prostatitis involving the body of tlie gland and cystitis are often con- 
founded. Desnos has modified and improved the table of differential 
diagnosis prepared by Fournier. 



Cystitis. 

1. Characteristic vesical tenesmus. 
Frequent desire to urinate imperative. 

2. Urination especially painful dur- 
ing the passage of the last drops of 
urine, accompanied by characteristic 
spasm. 

3. With the last portion of the urine 
expression of a purulent or bloody flow, 
often even of pure blood. 

4. Slight perineal pain radiating in 
the region of the anus, much less violent 
than in prostatitis. 

5. Prostate normal. 

6. No complete retention of urine. 

7. Few or no general symptoms. 



Prostatitis. 

1. Vesical tenesmus less. Rectal te- 
nesmus more marked. 

2. Urination distressing or painful 
during the whole act. 



8. Urine ordinarily normal. 



4. Perineal pain marked, very intense, 
increased by movements, defecation. 

5. Prostatic tumor, very sensitive and 
hard. 

6. Difficulty in passing the urine,' 
sometimes retention. 

7. General symptoms very marked, 
fever, etc. 



Cowperitis is distinguished by recognizing the seat of the inflamma- 
tion to be the anatomical region of Cowper's gland in front of the deep 
urethra and by excluding prostatitis by rectal examination. A seminal 
vesiculitis may be present with the same symptomatology as that of pros- 
tatitis, but is easily recognized at the onset by rectal examination. 

When periprostatitis occurs, the swelling diffuses itself in the sur- 
rounding tissues, including the seminal vesicles, and the recognition of 
the original trouble may then be much more difficult. 

Treatment, — The treatment of acute follicular prostatitis is that of 
posterior urethritis, which see. 

The aim of treatment in acute parenchymatous prostatitis should be 
to prevent the occurrence of suppuration,^ and calls for antiphlogistic 
measures. Hot sitz-baths or hot applications to the perineum are gener- 
ally a source of comfort to the patient, in which case they should be used 
freely. In very acute cases the application of cups, leeches, or a blister 
to the perineum is desirable, for the purpose of relieving the inflamed 
organ by lowering its tension. Anodynes may be given to allay pain, 
which is sometimes exceedingly acute and often remains in spite of the 
use of such remedies, pushed almost to the point of narcotism. Mor- 
phine hypodermically and suppositories of opium, belladonna, and cocaine 
may be employed. Confinement to bed is essential. No other medicinal 
treatment has any particular value. The diet should be plain, the bowels 
be assisted. The urine, if highly charged and acid, should be diluted by 
alkaline diuretics, and if retention occur, the catheter must be used very 



ACUTE AND CHRONIC PROSTATITIS. 77 

regularly and with the utmost gentleness. It is generally the case in 
acute parenchymatous prostatitis that relief from the acute pain is not 
had until the tension in the gland is relieved by the subsidence of the 
inflammation ; or, when suppuration occurs, until the evacuation of the 
pus. When it becomes evident that pus has formed, it must be let out 
at once. As already stated, the abscess may point toward the urethra, 
the rectum, or the perineum. When it points toward the urethra it often 
leads to urinary retention, and the pus escapes either spontaneously or 
during the use of the catheter. Superficial fluctuation, detected by rectal 
touch, calls for puncture through the wall of the gut. If the pus be 
deeply seated, a more surgical and better drainage is attained by the pre- 
rectal incision, dissection being carefully made upward until pus is reached. 
The advantage of this method is that urinary fistula is quite certainly 
averted. Nature even is sometimes intelligent enough to elect this route, 
in which instance a superficial incision is all that is required. The cavity 
is then washed out with hot normal salt solution, and if the hemorrhage 
be great, it is packed with absorbent gauze. The gauze may be removed 
in twenty-four or forty-eight hours, and replaced or not, as seems best. 
The after-treatment consists in keeping the external opening pervious 
until the cavity contracts down, which should be encouraged, if neces- 
sary, by stimulation. This, however, is generally not required, as, when 
proper drainage is afforded, the cavity rapidly contracts. 

Chronic Prostatitis. 

This malady is usually a direct propagation by continuity of chronic 
posterior urethritis, and it may yield symptoms of so little note as some- 
times to be entirely overlooked and disregarded, consisting only of a little 
sticky discharge which usually glues together the meatus in the morning. 
At other times the discharge is more copious and annoying. 

Prostatorrhoea is a disorder which resembles chronic prostatitis, in 
that it is a mild and chronic condition accompanied by few or no symp- 
toms other than a small amount of urethral discharge appearing at vary- 
ing intervals. The discharge in prostatorrhoea is not muco-purulent, but 
simply an excess of the normal prostatic secretion ; and the malady has 
not necessarily any venereal origin. These two troubles are often con- 
founded and the terms used interchangeably. 

Sturgis' has directed attention to this confusion that exists in the 
printed descriptions of the two maladies, and has clearly accentuated the 
points of difference. Chronic prostatitis then is a latent inflammation, 
a remnant of pre-existing acute trouble ; whereas prostatorrhoea, a more 
rare disorder, consists in a leakage of the prostatic secretion due to the 

^ Journal of Cutaneous and Genito-Urinary Diseases, June, 1898. 



78 VENEREAL. DISEASES. 

relaxation of the mouths of the prostatic ducts, and may be caused by 
masturbation, excessive sexual indulgence, etc. Both of these maladies 
are liable to be attended by various reflex nervous phenomena, psychical 
disturbances, and sexual debility and neurasthenia. The significance of 
the discharge is overestimated by the patient, who often, particularly in 
prostatorrhoea, imagines that the flow is a seminal loss, and he therefore 
aggravates all his symptoms by mental introspection. Instead of this 
mild type of prostatitis which approaches so nearly to prostatorrhoea, 
there is another type in which the suppuration in the prostatic sinus is 
very profuse, the dilated sinus containing not drops of pus but drachms, 
as may be demonstrated by washing out the pouch. One or more of the 
follicles of the prostate may be distended with pus, which exudes from 
their dilated mouths into the prostatic sinus. There may exist an inter- 
stitial prostatic pus cavity, the remnant of an old prostatic abscess, which 
has not contracted down. Examination per rectum in chronic paren- 
chymatous prostatitis will detect prostatic enlargement, generally unsym- 
metrical, sometimes nodular, and pressure upon the gland will express a 
quantity of its fluid contents, which will consist of pus cells and prostatic 
secretion, differing from that which is obtained by pressure in a case of 
prostatorrhoea, which consists of prostatic secretion pure and simple, and 
is devoid of the products of inflammation. 

There is an interstitial form of chronic prostatitis involving cellular 
infiltration of the gland and the obliteration of its glandular elements by 
the formation of new fibrotic tissue. Such a condition may eventually 
lead to atrophy, contractiou, and diminution in the size of the organ. 
There is no distinct line of demarcation between the follicular, the par- 
enchymatous, and the interstitial forms of prostatitis, any one of which 
may occur alone. They are liable to coexist, and the classification is 
more or less arbitrary. 

Symptoms. — Chronic prostatitis often exists without any symptoms of 
suflicient moment to attract the attention of the patient, and this may be 
true of active as well as of light cases. A chronic follicular prostatitis 
involving the ejaculatory ducts and the prostatic sinus may be attended 
by pain during the sexual act and a certain amount of purulent discharge. 
A much higher grade of trouble, involving even interstitial changes and 
parenchymatous inflammation, may exist without a corresponding increase 
in the intensity of the symptoms. Heat and bearing down in the peri- 
neum or rectum are sometimes complained of. Neuralgic pains radiating 
down the legs and toward the fundus of the bladder sometimes are the 
chief annoyance. Reflex nervous symptoms and mental depression are 
often present, but belong equally to the clinical history of all chronic 
disturbances of the genital apparatus, and therefore are not pathogno- 
monic. Functional impotence occurs or premature ejaculation due to 
hypersesthesia of the ejaculatory ducts. Sterility is possible from 



ACUTE AND CHRONIC PROSTATITIS. 



79 



azoospermia, caused by obstruction of the seminal ducts or by inflam- 
matory cohesion. 

Prostatorrhoea, or excessive flow of the prostatic secretion, may be 
present, due to dilatation of the excretory ducts of the prostate, in which 
case, however, inflammatory products are found mingled with the pros- 
tatic discharge. This discharge, as in prostatorrhoea simplex, may be 
increased by movements of the body and by defecation. True sperma- 
torrhoea, as shown by the presence of spermatozoa in the discharge, the 




Fig. 46, 



result of inflammatory catarrhal dilatation of the seminal ducts, often 
complicates chronic prostatitis. The prostate is always sensitive when 
examined per rectum, a feature more or less marked in different individ- 
uals. The nature of the discharge obtained by pressure upon the prostate 
varies, being sometimes a free gush of normal prostatic secretion with the 
admixture of a small amount of purulent matter, at others a large quantity 
of pus combined with only a few of the elements of the normal prostatic 
fluid, demonstrating that while these two conditions of prostatorrhoea and 
prostatitis may be differentiated theoretically, yet clinically they are less 



80 



VENEREAL DISEASES. 



easily separated and are liable to coexist. Strictly speaking, prostator- 
rhoea is a symptom, not a disease — a symptom which generally enters the 
clinical history of prostatitis more or less. 

Diagnosis. — A strict diagnosis of chronic prostatitis depends upon the 
character of the prostatic secretion squeezed out by digital pressure per 
rectum. The subjective symptoms are not to be relied upon. Micro- 
scopical examination of the discharge is important to differentiate prosta- 
titis, prostatorrhoea simplex, spermatorrhoea, urethritis, and urethrorrhoea. 




Fig. 47. 

In making such investigation it is important to examine first the discharge, 
if any, which may be lying in the anterior urethra; next, that which is 
found in the urine after the anterior urethra has been washed or after the 
first flow of urine; and finally that which is found in the last urine 
after the prostate shall have been manipulated through the rectum. The 
physical character of the urethral discharge is known to vary in the dilfer- 
ent conditions named. A purulent discharge signifies an inflammation in 
the anterior or posterior portion of the canal. Prostatorrhoea simplex, as 
already stated, yields an excess of prostatic secretion, which escapes from 



ACUTE AND CHRONIC PROSTATITIS. 



81 



the urethra spontaneously and during muscular effort. Such a discharge 
is neutral or mildly acid in reaction. It has the seminal odor. It is 
white in appearance and is smooth and slippery. A microscopical exami- 
nation reveals the accompanying picture, which contains amyloid, hyaline, 
and lecithin bodies, epithelium and Boettcher's crystals (Fig. 46), the 
latter being seen only in secretions from the prostate and are produced 
by the addition of a one-per-cent solution of phosphate of ammonia. 
This secretion, as will be seen, possesses none of the elements of inflam- 




FlG. 48. 



mation. Its presence here would indicate the coexistence of prosta- 
titis, from which, theoretically at least, prostatorrhoea simplex must be 
clearly distinguished. 

Urethrorrhoea ex libidine consists of a hypersecretion from the glands 
of the urethra. The discharge is thin and watery, sticky and tenacious, 
and the patient may notice that upon placing his finger over the meatus 
the discharge may be drawn out for some little distance, resembling in 
this particular a bit of gum or sap. It has no seminal odor audit consists 
microscopically of a collection of flat epithelial cells and some free mucus, 
6 



82 



VENEREAL DISEASES. 



but none of the elements which are found in the secretion of a prostator- 
rhoea (I'ig. 46). This discharge is also, in an uncomplicated case, en- 
tirely free from the elements of inflammation. 

Spermatorrhoea produces a discharge which is gelatinous in character, 
mildly alkaline in reaction, and possesses the seminal odor. Microscopi- 
cally we find the unmistakable evidence of the character of this discharge 
in the presence of spermatozoa (Fig. 48). We have also the elements of 
the prostatic secretion, and in inflammatory conditions we find the elements 




Fig. 49. 

of inflammation ; but the presence of spermatozoa in a secretion from the 
urethra at any time except following an emission is the one sign necessary 
to determine the existence of spermatorrhoea, which condition may exist 
as a result of an atonic state with dilatation of the seminal ducts, or as a 
symptom of prostatitis or vesiculitis. The discharge of prostatitis may 
be scanty or abundant. It oozes spontaneously from the urethra, but in 
order to establish its origin it is better first to wash out the urethra with 
warm saline or boric-acid solution and then obtain the discharge for exam- 
ination from the first flow of urine, or to examine that which is expressed 



ACUTE AND CHRONIC PROSTATITIS. 83 

from the gland by pressure through, the rectum. The gross appearance of 
this discharge is more or less purulent, differing from that of prostatorrhoea 
and that of urethrorrhoea which do not possess this characteristic. It has 
nothing whatever in its gross appearance to distinguish it from the in- 
flammatory discharge of other portions of the canal, and it is therefore 
important that it be obtained for examination after the anterior urethra 
shall have been cleansed. It is a difficult matter to determine by micro- 
scopical examination the locality from which the epithelium in a given 
specimen is derived. The exudation from a chronic prostatitis will pre- 
sent a microscopical picture, as shown in Fig. 49, containing granular 
phosphates, leucocytes and epithelia, and in addition any of the elements 
of the normal prostatic secretion as seen in prostatorrhoea (Fig. 46) may 
be found. 

The gross appearance of the urine in chronic prostatitis may show only 
the presence of urethral filaments or of a small or large quantity of 
free pus. In locating the origin of urethral filaments or of the free pus, 
it is proper to take the precaution of first cleansing the anterior canal and 
then obtaining the urine in two separate flows. The first flow will then 
wash out the contents of the prostatic canal, which may be a quantity of 
free pus or one or two shreds or lumps, and the latter will present differ- 
ent appearances, as they happen to be more or less granular or gelatinous. 
There is sometimes a solitary shred of a definite tadpole shape as though 
it had been expelled from the mouth of one of the ejaculatory ducts. 
Microscopically they are composed of pus cells and mucus, and also may 
contain any of the other elements of the prostatic or seminal secretion. 
The examination per rectum will distinguish any alteration in the size 
and sensibility of the prostate, and also any implication of the seminal 
vesicles, which, if distended by catarrhal secretion, may be felt beyond 
the prostate on either side of the base of the bladder, varying in size 
from a peanut to that of a small egg. Cystitis of the neck of the bladder 
is readily identified by the frequency and pain of urination, notably at 
and after the expulsion of the last portion of urine, and often by the ex- 
istence in the last flow of a greater amount of pus than in the beginning. 
Cystitis often coexists with chronic prostatitis. 

Treatment, — In the adoption of local treatment for chronic prostatitis, 
by way of the urethra, certain measures have been recommended which, 
in our opinion, are a source of irritation rather than a means of relief. 
Such are the unnecessary passage of bougies and other instruments intended 
to overdilate the canal, and the use of medicated bougies. Some cases 
of chronic prostatitis require about the same treatment and management 
as that recommended for chronic urethritis (see p. 43), mild irrigations of 
permanganate of potassium, about 1 : 4,000 to 6,000, or of the nitrate of 
silver or corrosive sublimate, the former 1 : 4,000 to 6,000 (and when 
well tolerated even stronger), the latter 1 : 12,000 to 16,000. The 



84 



VENEREAL DISEASES. 



method of irrigating the prostatic urethra has been already described 
(page 28). Instillations are also often found useful in chronic prosta- 
titis. The nitrate of silver heads the list. It should be tested gently, 
for it may disagree. It is used in a solution of from gr. ss. to gr. x. to 
the ounce, and sometimes stronger, and probably more often than the 
other preparations because it is quite generally effective, often brilliantly 
so. A few drops only of the strong solutions are needed, the quantity 
being reduced as the strength of the solution is increased. Thallin and 



Fig. 50.— Tuttle's Rectal Tube. 

the other drugs already referred to (see p. 47) will be found to suit 
some of these cases. The use of the endoscope in the posterior urethra 
has already been discouraged. The authors of this treatise can do better 
with other means. It is, however, advocated by some, who claim better 
results by this means than by other methods. The Griinfeld endoscope 
is advocated for the purpose of making direct application of the caustic 
agent, nitrate of silver or chloride of zinc, to the veru montanum. It is 
not clear why such active cauterization of the veru montanum should be 
better than gentler astringent applications to the entire prostatic sinus, 
more particularly if the parenchyma of the prostate be involved as well 
as the surface of the mucous membrane. 

To reach deep-seated chronic inflammatory alterations of the prostate, 




FIG. 51.— Chetwood Tube for Rectal Irrigation. 



such measures as will act directly upon the circulation of the organ may 
be instituted. One of these is massage of the prostate, accomplished by 
the finger introduced into the rectum. Gentle lateral pressure may thus 
be made upon the prostatic tissues, while at the same time the secretion 
in the swollen and turgid follicles is forced out. This, both to the 



ACUTE AND CHRONIC PROSTATITIS. 



85 



patient and the surgeon disagreeable manipulation is sometimes quite 
useful in very chronic cases. Many trained nurses and massage opera- 
tors understand and practise it. But better than this last procedure we 
consider the application of moist heat to the region of the prostate by 
rectal irrigation. It is a fact that the rectum will tolerate a very high 
degree of temperature when employed in this manner, and sometimes by 
this means strikingly beneficial results are obtained in old chronic cases 
of prostatitis which have long resisted the continued efforts directed tow- 




FIG. 53. 



ard the urethral surface of the gland. The figure on this page illustrates 
the method of employing the hot-water rectal douche by means of a tube 
especially devised for this purpose — a modification of Tuttle's or Kemp's 
rectal tube (Fig. 51). The hot water from a fountain syringe passes 
into one arm of the tube and enters the rectum through two very small 
apertures on its circumference near the distal end. A large opening at 
the extremity connects with an interior tube as large as the calibre of the 
outer one will allow. Through this the immediate return of the hot 
water from the rectum takes place, and thus a continuous circulation of 



86 VENEREAL DISEASES. 

moist heat around the prostate is kept up so long as the operation is con- 
tinued, which is generally from ten to fifteen minutes. The end of the 
tube needs a little manipulation to insure continuous outflow of the 
injected fluid. Instead of the sitting posture which is assumed in the ac- 
companying figure, the knee-chest position may be substituted and often 
with better results. This operation should be conducted every night for an 
extended period, according to the effect produced. Improvement is often 
noted almost immediately, and sometimes it is surprising to discover that 
in the absence of any other local treatment the character of the urine, 
which had been thick and turbid with pus, clears up promptly. Most 
cases, however, are less brilliant, and it is sometimes necessary to urge 
the continued use of this rectal tube for a long period before permanent 
results are obtained; but when improvement has taken place under its 
use, permanent relief may be hoped for if the douche be used persist- 
ently. The general condition of the patient should receive attention, and 
any disturbances of nutrition properly treated. Iron, arsenic, and hypo- 
phosphites have their mdications as tonics, and cod-liver oil seems to 
possess a special value, as in most other debilitated conditions. Pros- 
tatitis may be tuberculous in character, or occur in individuals who have 
the tuberculous diathesis. Indeed, posterior urethritis is not infrequently 
the exciting cause of local tuberculous deposit. Such cases naturally do 
not get well under instillations, irrigations, or the rectal douche. Thallin 
sometimes comforts them, and the hot rectal douche does the same, but 
radical treatment means a transportation to a favorable climate, plus the 
usual internal constitutional remedies directed against tubercle wherever 
situated. 

Inflammation of the Seminal Vesicles. 

Inflammation of these organs, or spermatocystitis, occurs as a gonor- 
rhoea! complication following severe or prolonged suppuration in the pos- 
terior portion of the urethra. It frequently coexists with inflammation 
of the prostate and often with acute epididymitis, but in such cases it is 
a side issue and may be disregarded until the epididymitis shall have 
disappeared. Any inflammatory condition existing in the prostatic sinus 
may extend by continuity into the vesicular reservoirs, but gonorrhoeal 
posterior urethritis is more liable to take this course than other inflam- 
mations. It is claimed by some that this propagation of inflammation 
from the prostate is by way of the blood-vessels or lymph channels, but 
the claim has not been substantiated. That seminal vesiculitis may exist 
as a separate and distinct affection there is no possible doubt, but it is 
most often a complica'tion of gonorrhoea which has invaded the posterior 
urethra. 

The symptoms of acute seminal vesiculitis resemble those of acute 
posterior urethritis and prostatitis; sometimes there is more fever. 



INFLAMMATION OF THE SEMINAL VESICLES. 87 

They are a sense of pressure, pain, and rectal tenesmus, painful erec- 
tions, and sometimes spermatozoa in the urethral discharge and purulent 
or bloody seminal emissions. This latter is by no means a constant 
symptom. Examination per rectum will detect an enlarged and tender, 
sometimes fluctuating mass in the region of the vesicles, extending from 
the limit of the prostate upward along the base of the bladder on one or 
both sides. When abscess forms, as is sometimes the case, it may dis- 
charge itself forward into the urethra or backward into the rectum. Such 
abscesses have been known to point into the abdominal cavity, causing 
fatal peritonitis. The symptoms not being entirely distinctive of this 
disorder, the diagnosis must depend upon rectal examination. When 
vesiculitis coexists with prostatitis, the swelling and infiltration will be 
found to destroy the line of separation between these organs ; but when 
it is limited to one or both vesicles, a careful exploration may distinguish 
the outline of the prostate. 

Chronic Seminal Vesiculitis. — This is usually a natural sequence of 
the acute trouble, or may come on insidiously as a complication of the 
chronic gonorrhoeal urethritis which has invaded the posterior urethra 
and thence extended itself to the prostate and vesicles. It is often due 
to excessive sexual indulgence, even without an antecedent gonorrhoea, 
or to the abuse of venery and alcohol, or to the employment of harsh 
local treatment in the posterior urethra during a congested or inflamma- 
tory state. It is probable that tuberculous and rheumatic subjects are 
more prone to chronic vesiculitis, as they are generally more likely to be 
the victims of prolonged and intractable attacks of posterior urethritis. 

The symptoms of chronic vesiculitis resemble those of chronic pros- 
tatitis, and vary greatly in severity. Sometimes there is no symptom 
other than a chronic urethral discharge, which has resisted all the various 
local and general therapeutic attacks. In addition, there may be noted 
frequent nocturnal pollutions, bloody or purulent in character. Altera- 
tions in the sexual capacity and appetite may also be a feature. Neuras- 
thenic symptoms, as in prostatitis, are commonly present, and indefinite 
and intermittent pains radiating through the perineum, down the thigh, 
and into the hypogastric and lumbar region may also be complained of. 

Treatment. — The treatment of seminal vesiculitis resembles that 
adopted for acute and chronic prostatitis. During acute inflammation rest 
and freedom from all sexual excitement are imperative, and antiphlogis- 
tic measures suitable in the endeavor to avert suppuration. A bland 
diet, alkaline diluents, and mild laxatives, together with hot sitz-baths or 
hot applications to the perineum, are all in order. If an abscess forms in 
spite of these measures, its contents should be evacuated by a rectal in- 
cision as soon as fluctuation can be distinctly made out. Massage and rec- 
tal douches are not only improper in the acute stage, but are liable to 
cause irritation and do harm. When the abscess has discharged itself 



88 VENEREAL DISEASES. 

spontaneously or by incision and the acute symptoms have subsided, treat- 
ment becomes the same as that employed in the chronic condition. 

In chronic inflammation of the seminal vesicles infiltration and vas- 
cular engorgement of these pouches exist with sometimes narrowing or 
occlusion of the ejaculatory ducts, but usually catarrhal dilatation. The 
aim of treatment is to facilitate drainage of the distended catarrhal 
pouches and by improving the circulation to overcome the catarrh. For 
this purpose a systematic massage of the vesicles themselves and of the 
adjacent prostatic region has been strongly advocated, notably by Dr. 
Eugene Fuller ; a process termed " stripping the seminal vesicles " being 
relied upon to effect a cure. That many cases are benefited by this, 
what may be called drainage method, there is no doubt ; but if equally 
good results can be obtained by other means, the irritation, which is 
sometimes caused by pressure upon the vesicles, may be avoided, and 
the surgeon will necessarily give his preference to another equally effec- 
tive procedure, especially as the regular employment of the alternative 
stripping measure is not agreeable, and may be as well carried out by a 
trained nurse. For this purpose we have used in many cases the rectal 
irrigating-tube already referred to when considering the treatment of 
prostatitis (page 85, Fig. 52). By this application of moist heat a 
beneficial result may be looked for in this region, whether the inflamma- 
tion involve the prostate alone or coexist with a catarrhal distention of 
the seminal vesicles. This hot-douche irrigation brings about the same 
results as the application of massage. It assists the overdistended vesi- 
cle in voiding its contents, and by its resolvent action upon the circula- 
tion encourages resolution of long-standing inflammation. An additional 
advantage is that it can be employed by the patient himself, and no 
matter where he may be, it is generally possible for him to obtain the 
benefit of continuous treatment when circumstances might not permit 
him to make frequent calls upon his physician. In long-standing and 
chronic cases, like massage it should be persisted in patiently over a long 
period. Some cases yield to it which have not been favorably influenced 
by massage. Some are entirely cured by it, others greatly improved. 
Those that fail to improve are quite likely to be tuberculous or to have 
prostatic hypertrophy or contractured vesical neck, conditions equally 
unsuitable for massage. The last-named condition — contracture of the 
neck of the bladder — is not an infrequent result of prolonged suppurative 
inflammation m the posterior urethra. If its symptoms are urgent, they 
call for perineal cystotomy for the purpose of incising laterally the 
fibrotic ring, a means which alone insures relief of symptoms. 



CHAPTER V. 

ACUTE AND CHEONIG CYSTITIS.— EPIDIDYMITIS. 

Inflammation of the neck of the bladder may complicate urethritis 
under a variety of circumstances. It very rarely occurs spontaneously 
during gonorrhoea. Generally some immediate exciting cause produces 
it. Among the most common of these are the use of strong injections, 
especially if thrown too deeply into the canal; strong and continued 
sexual excitement, or attempts at intercourse during a gonorrhoea ; excess 
in physical exertion of any sort ; abuse of liquor ; excessive use of cubebs, 
turpentine, or cantharides j the use of instruments in the urethra during 
an acute attack, or at any stage if there be any lack of perfect gentleness 
in manipulation during such instrumentation. 

All of these, and certain other analogous causes, are sufficient to excite 
gonorrhoeal cystitis in a patient having a urethral discharge, although the 
attack itself may have become very mild, and much the more so when 
the symptoms are intense. The same exciting causes are also sometimes 
productive of cystitis when the urethritis is due to the presence of stric- 
ture, and not very infrequently an attack of mild cystitis comes on in a 
patient with a diseased urethra, the exact immediate cause of which can- 
not be determined. 

Gonorrhoeal cystitis is often not encountered until the urethral dis- 
charge has been active for several weeks, but may come on earlier. 

The lesions of acute gonorrhoeal cystitis are generally confined to the 
neck of the bladder, and with them are likely to coexist lesions of the 
posterior urethra. The term urethrocystitis has been applied to this 
condition, signifying inflammation commencing in the posterior urethra 
and extending into the bladder, where it is limited to the region of the 
trigone and internal sphincter. 

Acute cystitis proper, involving the entire surface of the vesical 
mucous membrane, is a rather rare complication of gonorrhoea, but does 
occur. 

In urethrocystitis the mucous membrane in the vicinity of the neck 
of the bladder becomes swollen, red, and velvety, in continuation of a 
similar condition in the prostatic urethra. When this process has existed 
for some time and become subacute or chronic, the neck of the bladder is 
covered with granulations; while if the entire organ is involved, the 



90 VENEREAL DISEASES. 

general mucous membrane assumes a slate color and a reticulated appear- 
ance, and may be the seat of ulcerations or small abscesses. If this 
morbid change extends still farther, a " parenchymatous cystitis " is the 
result, the deep portions of the mucous membrane are implicated, and the 
muscular coat becomes infiltrated. 

Finally the pelvis of the kidney on one or both sides may become 
invaded from propagation of the inflammation upward through the 
ureters. The gonococcus is found in the pus in some cases. In many 



Fig. 53.— Acid Cystitis. Pus corpuscles, red blood cells, and bladder epithelium. 

its presence cannot be demonstrated, while other micro-organisms are 
found in large numbers. 

The urine in gonorrhoeal cystitis varies according to the character and 
intensity of the inflammation. In the acute stage it is generally acid, 
loaded with pus, and contains epithelium from the bladder and urethra, 
sometimes blood (Fig. 53). When decomposition takes place within the 
bladder, the characteristic crystals of ammonio-magnesium or triple 
phosphates, amorphous phosphates, and sometimes urate of ammonia 
crystals with numerous bacteria are seen on microscopical examination 
(Fig. 54) . Such urine is alkaline in reaction and has a characteristic foul 
ammoniacal odor. 

Symptoms. — The symptoms of gonorrhoeal cystitis vary with the in- 



ACUTE AND CHRONIC CYSTITIS. 



91 



tensity of the inflammation. They are frequent desire to urinate, ac- 
companied by a varying amount of pain and urgency, and the passage 
of turbid, purulent urine. 

In all forms of cystitis there exists a certain amount of urinary urgency, 
which while mild and controllable in light cases, becomes intense and im- 
perative in the acute condition, accompanied by sharp pain and hsematuria. 
The blood may appear as a coloration of the last drops of urine, or be 
of sufficient quantity to redden the entire flow. In acute urethro-cystitis 






r^mS i '. /^■^rt^^- f^-^'iA ''-'-^^ ^v 







Fig. 54.— Alkaline Cystitis. 



Pus corpuscles, bladder epithelium, crystals of triple phosphates, 
and bacteria. 



the symptoms are mainly those of acute posterior urethritis, varying in 
intensity from a slightly increased desire to urinate, with bearing-down 
pain toward and after the end of the urinary act, to a much greater 
urgency in the calls, which become as frequent as every quarter to half 
hour, attended perhaps by hsematuria due to the high grade of conges- 
tion. Each spasmodic effort to empty the bladder rubs together the 
inflamed surfaces of the mucous membrane and intensifies the condition. 
When the urine is passed into two glasses both flows are turbid, the 
second being as cloudy as the first, and sometimes more so. If the urine 
is passed into three separate glasses the third flow will also be cloudy 
from the presence of pus, sometimes more and sometimes less so than 



92 VENEREAL DISEASES. 

that in the first glass ; but it will always be turbid, which is not the case 
when the posterior urethra alone is involved. Involuntary urination or 
false incontinence occurs in acute cases when the calls to urinate are 
imperative, the patient being unable to restrain the bladder contraction. 
Complete retention sometimes occurs, but infrequently and as a result of 
urethral spasm, whereas incomplete retention due to swelling of the tis- 
sues around the neck of the bladder is less uncommon. 

In chronic urethro-cystitis the symptoms are the same but milder, 
and as time goes on they gradually diminish unless the vesical neck be- 
comes contractured, in which case they persist almost indefinitely. 
Chronic cases are always subject to acute relapse. As a result of pro- 
longed chronic inflammation and infiltration, acting as an obstruction to 
the evacuation of its contents, the bladder atonies and the presence of a 
certain amount of residual urine may become constant. This urine may 
be of acid reaction, containing all the elements of inflammation ; or if 
decomposition has set in, it may show all the characteristic elements of 
ammoniacal urine (Fig. 54). 

As urethro-cystitis comes on, the patient at first passes water a little 
more often than usual by day (sleeping perhaps through the whole night), 
and the urethral discharge lessens, which is taken by the patient to be a 
favorable sign. Soon, however, it is found that the calls to urinate 
become more urgent. Then follow pain on urination, and a sharp, 
grinding, bearing- down pain following each act of urination, due to the 
fact that the empty bladder continues to contract and squeezes its own 
tender neck. 

From this time on there is a constant sense of weight, a dull pain 
over the pubic symphysis, more or less heat and discomfort in the peri- 
neum, a constant sensation of fulness of the bladder, callmg for repeated 
and unavailing straining to pass water, the best efforts culminating in a 
spurt of only a few drops of turbid urine full of pus and often tinged 
with blood. When this state has been reached the patient may become 
feverish, with dry tongue, parched lips, and constipated bowels. 

Gonorrhoeal cystitis generally gets perfectly well in a period varying 
from a few days in mild cases up to a couple of weeks, or even several 
months, in bad cases. Sometimes permanent irritability is left behind, 
and persists as a chronic cystitis, with more or less fibrotic thickening — 
contracture — of the vesical sphincter and a relative amount of occlusion 
of the urethral orifice of the bladder. 

Treatment, — In mild cases rest upon the back may be all that is re- 
quired in the way of treatment. The application of heat, as in a hot- 
water bottle, affords considerable comfort when placed over the bladder 
or against the perineum. 

The alkaline diluent, copaiba or sandal-wood oil, if being administered 
for urethritis, should be continued, and bland drinks, like flaxseed tea. 



ACUTE AND CHRONIC CYSTITIS. 93 

elm-bark decoction, infusions of triticum repens, bucliu, afford the patient 
some comfort, but do not do much good, excepting in so far as they are 
mildly diuretic. ' 

Diluent mineral waters drunk freely are unquestionably of value in 
these cases, and an exclusive milk diet has a peculiar merit. The latter 
must be accompanied by enough of some mild vegetable laxative to over- 
come its constipating tendency. If it purges, as is sometimes the case, 
skimmed milk may be substituted for whole milk. A gallon a day is full 
diet for a healthy man. If so much can be managed by the stomach, 
nothing else whatever need be given either to eat or to drink. 

All those articles of food and drink which were condemned in the 
dietetic section on the treatment of gonorrhoea must be equally avoided 
here. 

Hot hip-baths are of service. The heat of the bath should range in 
the region of 110° F., the pelvis should be covered by the water-line, 
and the bath be not longer than three or four minutes in duration. Such 
baths may be repeatedly taken every few hours during the day when they 
afford relief. 

As for medicines, anodynes hold the first rank. The frequency of 
urination must be stopped. The following combination will give relief in 
mild cases : 

I^ 01. santal. or gaultheriae, . . . . . • 1 ss. 

Liq. potass^, 3 ij.-vi. 

Tr. hyoscyami, 3 vi. 

Syr. acacise, ...... q.s. ad | iij. 

M. S Teaspoonful in water every four hours. 

Hyoscyamus may be used alone, as tincture, in half-drachm doses several 
times a day, with the happiest effect in the cases in which it agrees. 

When mild measures of this sort fail to control the frequency of 
urination, a positive anodyne must be employed. Half-grain or whole- 
grain suppositories of the watery extract of opium, with one-third to one- 
half of a grain of the extract of belladonna, may be used and repeated 
often enough to keep the intervals of urination two hours long. The 
belladonna sometimes disagrees. A tablet triturate of codeine (one- 
quarter grain every three or four hours) may be used for the same pur- 
pose, to keep the intervals of urination two hours long by daylight, or an 
analogous liquid preparation : 

I^ Eiix. opii (McMuun), 3 vi.-xij. 

Liq. cascara aromat. , . . . . . . . ^ss.-iss. 

Aq. cimiamomi, ...... q.s. ad § iij. 

M. S. Teaspoonful three or four times a day. 

By persistence in these means, the pain, the tenesmus, and the fre- 
quency of urination will gradually subside, and the discharge begin to 



94 VENEREAL DISEASES. 

reappear at the meatus. For this return, some mixture of copaiba should 
be used internally, since the effect of this drug upon the bladder is often 
also quite beneficial. The following capsule is a good one : 

I^ Copaibas, "nivij. 

Oleoresin. matico, iTi iij. 

8. Three to six capsules daily. 

At this stage the question of resuming local measures against the 
urethral discharge may be properly considered. 

Local Treatment. — During the most acute stage of gonorrhoeal cystitis 
it is better to depend upon antiphlogistic measures and the internal treat- 
ment, which has already been detailed. Local measures are generally to 
be interdicted during this period, as they are liable to increase the irrita- 
tion rather than to allay it. When the acute stage has subsided, however, 
and in subacute and chronic cases generally, local measures are decidedly 
indicated. Some cases which seem to be irritated by local applications 
are benefited by irrigations with plain hot normal salt solution or boracic 
acid three per cent. Other cases are decidedly helped by irrigations of 
permanganate of potassium in the same manner as employed in acute 
anterior and posterior urethritis (p. 29). The value of this latter 
remedy in a given case is generally quickly determined. If the benefit 
be not prompt, the irrigations should be discontinued. Solutions of 
nitrate of silver sometimes prove more efficacious than any other remedial 
agent in the treatment of gonorrhoeal cystitis. The strength of such 
solutions varies from 1 : 16,000 to 1 :2,000, according to the tolerance of 
the bladder. They should be used in the same manner as the perman- 
ganate of potassium — that is, they should be injected into the bladder 
through the posterior urethra and thus their beneficial influence exerted 
upon this latter region. If after the cessation of the acute stage of cys- 
titis the urethritis has recurred and is accompanied by a more or less 
copious discharge of pus, it is well also to irrigate the anterior urethra 
before introducing the catheter for posterior irrigation, but this is neces- 
sary only when anterior urethritis is present. If permanganate of potas- 
sium is being employed for bladder irrigation, the anterior urethra can be 
irrigated in the regular way ; but if the nitrate of silver is being employed 
in the bladder, this agent should not be used for anterior irrigation, as 
its decidedly astringent effect upon the urethra will interfere with the 
introduction of the catheter and cause considerable annoyance. If irri- 
gation of the anterior urethra be deemed necessary, the permanganate of 
potassium should be used for this purpose or the urethra may be syringed 
out with plain boric or salme solution. When after a certain period the 
symptoms of cystitis have subsided, and the examinatioQ.of the urine in 
test glasses shows that the trouble has concentrated itself in the posterior 
urethra, the bladder irrigations may be discontinued and the treatment 



ACUTE AND CHRONIC CYSTITIS. 



95 



by instillation adopted as described under the treatment of chronic 
urethritis (p. 45). 

In cases of chronic cystitis the antecedent cause should be determined, 
as the persistence of such cause may largely influence the continuance of 
the bladder inflammation. In this we refer to the existence of stricture, 
chronic prostatitis, and chronic seminal vesiculitis. When found these 
conditions should be properly treated as has been detailed under their 
respective headings. The treatment of chronic cystitis proper requires 
local applications to the bladder and the use of a mild non -stimulating 
diet. Medication should vary according to existing conditions in a given 
case, as revealed by urinary examination and personal idiosyncrasy. A 
careful examination of the urine should be made in all cases. As already 
stated, such examination will show purulent urine containing various 
micro-organisms, sometimes acid in reaction and sometimes alkaline with 
ammoniacal decomposition. Alkalies and diluent mineral waters are 
indicated when the urine is strongly acid and of high specific gravity. 
Alkalies, however, should be used with discrimination and not to excess, 
as hyperalkalinity of the urine is to be guarded against. When the 
urine is alkaline, urotropin, salol, methylene blue are often of decided 
benefit as urinary antiferments, and will assist in restoring the urine m 
the bladder to its normal state. From gr. xxx. to Ix. of salol should be 
given daily in divided doses. One of the formulae put up in capsule 
form containing salol in combination is also sometimes useful. 



Formula 1. 



I^ Salol., . 

Oleoresin. cubeb., 
Copaib. Para, 
Pepsin., 

Capsule No. 1. 



gr. iiiss. 

TTl V. 
m X. 

gr. i. 



FOEMULA 2. 



I^ Salol., . 

Oleoresin. cubeb., 

01. santal., 

Pepsin., 

01. oliv.. 
Capsule No. 1. 



gr. IV. 

n V. 

Ta V. 

gr. i. 

TTl V. 



From six to eight of one or the other of the above ca,psules may be 
given in each twenty -four hours. Occasionally salol disagrees with the 
stomach, especially m large doses. It may m such cases color the urine 
a smoky green when it should be stopped. 

Bacteruria is a constant symptom of chronic cystitis, and sometimes 
very difficult to overcome. As already stated, salol is sometimes very 
useful m re-establishing the normal aseptic condition of the urine. 
When this drug f ailS; one of the other internal antiseptics may be resorted 



96 VENEREAL DISEASES. 

to. Methylene blue in capsule form, gr. ij. three times a day, is given 
for this indication, and often with good effect. It rapidly colors the 
urine bluish-green, and is objectionable on this account as it is liable to 
stain the patient's linen and sometimes deranges the stomach and bowels. 
Urotropin, the ammonia salt of formaldehyde, has been recommended 
as a uric-acid solvent and as an internal antiseptic. In some cases its 
effect is markedly beneficial in conditions of pyuria or bacteruria, and 
in others it seems to be a source of irritation to the stomach and mucous 
membrane of the urinary tract. It may be given in five- to ten-grain 
doses from three to six times daily, in tablets or in powder form. 
Cystogen is an analogous preparation which may be given in the same 
quantity. 

The local treatment of chronic cystitis calls for bladder irrigations of a 
rather more stimulating character than in the acute form. The perman- 
ganate of potassium is sometimes useful. Nitrate of silver, when well 
tolerated, should be employed in increasing strength from 1:4,000 to 
1 : 2,000, sometimes even 1 : 1,000. Bichloride of mercury in solutions of 
from 1:16,000 to 1:10,000 and protargol, 1:1,000 to 1:250, are also 
used. There is no given rule upon which to base a selection of one or 
the other of these remedial agents in the local treatment of chronic 
cystitis, as their beneficial effect is not constant for all cases, some being 
aided by one and some by another preparation. When after a long use of 
local treatment chronic cystitis seems to resist all the measures adopted, 
perineal cystotomy should be considered for the purpose of affording pro- 
longed drainage to the inflamed organ. If this expedient be decided 
upon, the bladder should be opened by a central perineal incision, as de- 
scribed in the treatment of stricture; and if it be found that the bladder 
is covered with velvety granulations, the curette may be resorted to with 
perfect safety and often with excellent effect. If contracture and hyper- 
trophy of the vesical sphincter be discovered, as is often the case, a 
rigid vesical orifice resisting the exploring finger, this obstruction, which 
explains the persistence of the chronic cystitis, should be cut down 
freely by a lateral incision with a long blunt-pomted bistoury introduced 
into the bladder under the guidance of a grooved director, the depth of 
the cut being estimated by a finger passed into the rectum, toward and 
upon which the incision is made. 

GONORKHCEAL EPIDIDYMITIS SwELLED TeSTICLE. 

Epididymitis, as a complication of gonorrhoea or urethritis, is more 
frequent m hospital than in private practice, where Bergh finds it in 
about seven per cent of the cases, while Taylor places it at not over two 
to three per cent. Like gonorrhoeal cystitis, it may come on in regular 
sequence as a result of the gradual spreading downward of the urethral 



EPIDIDYMITIS. 97 

inflammation, from the posterior urethra to the mouth of the ejaculatory 
duct, and thence through the vas deferens to tho testicle. Its most com- 
mon date of appearance, in the course of a gonorrhoea, is daring the first 
three or four weeks. 

The date of appearance of epididymitis, however, is by no means 
fixed. It may come on during the first few days as a result of irritating 
injections, and it may be encountered at any period later, or even at any 
time afterward during life. Stricture of the urethra, or rather posterior 
urethritis so constantly existing behind it, is a fertile source of epididy- 
mitis. Both testicles are attacked with equal frequency, but not simul- 
taneously. Epididymitis is generally unilateral, and when both testicles 
are swelled one follows the other by an interval more or less long. 

Generally, epididymitis is due to some direct exciting cause over and 
above the general inflammation of the urethra. Among such immediate 
causes may be enumerated most of those irritants, general and local, 
which have been referred to already as being capable of lighting up 
cystitis in a patient with gonorrhoea, such as injections too irritating in 
quality or thrown too deeply into the canal ; the passage of a sound or 
other instrument, for exploratory or other purposes, down a urethra 
which is the seat of surface inflammation ; sexual irritation of any sort ; 
drinking; violent exercise, which may act by directly damaging the 
testicle mechanically, and thus, as it were, calling down the inflammation 
from the urethra. 

Ordinary swelled testicle is usually a direct sequence of posterior 
urethral inflammation. This inflammation extends through the vas 
deferens, producing inflammation of the duct (def erentitis ) and lodges in 
the epididymis alone (epididymitis) or occasionally extends farther into 
the testicle (epididymo-orchitis). A testicle once attacked by epididy- 
mitis is rather prone to relapse later on in life, more vulnerable, as it 
were, than its sound companion. 

Epididymitis is accompanied by considerable swelling of the organ, 
firm, resistant, due to inflammatory exudation and interstitial changes, 
consisting chiefly in infiltration of lymphatic cells. This condition may 
involve the testicle and the vas deferens. There is generally effusion into 
the tunica vaginalis and sometimes active inflammation of its walls. Ab- 
scess may result, but is infrequent. Examination of the serous fluid in 
the tunica vaginalis has revealed the presence of pathogenic micro-organ- 
isms and sometimes the gouococcus, but this latter does not play the most 
important etiological role in this complication. 

Symptoms. — When acute epididymitis is about to attack a healthy 
testicle, sometimes signs of warning may be appreciated twenty-four 
hours before the testicle begins to swell. The first sign is generally an 
uneasiness referred to the depths of the groin, upon the side about to 
become affected, with a sense of weight and uneasiness in the testicle of 
7 



98 VENEREAL DISEASES. 

that side, which is usually already somewhat over-sensitive to handling. 
With these symptoms there may be some general malaise, a little consti- 
pation, slight headache, a trifling fever. 

These symptoms are quite apt to come on in the afternoon after a day 
of ordinary exercise. 

The patient naturally keeps still with the pain in his groin or testicle, 
and the rest of an evening, or a night, or both, often makes him so com- 
fortable that, upon awaking the next morning, he may not be conscious 
that he has any unusual pain until he is upon his feet — possibly not then. 
Indeed, after quite a marked prodromal stage, a night's rest sometimes 
dissipates the pains, and the patient becomes and remains well. 

This fortunate result is rare. Generally, as the day goes on, the 
pain in the groin becomes more intense, the testicle rapidly or gradually 
grows heavy, hot. and painful. The enlargement usually commences in 
the upper and back portions — the globus major — and runs down the body 
of the epididymis; sometimes the lower part or globus minor is first 
involved. 

The portion affected is acutely sensitive to pressure; the remainder 
is not so. At this stage the different divisions of the epididymis and its 
separation from the body of the testicle can be readily marked out. 

Inflammation and swelling of the cord may occur simultaneously with 
that of the epididymis, or later on. There may be a sharp chill, followed 
by intense fever, nausea, headache, and vomiting. Constipation is apt 
to be present, and sometimes there is a tendency to frequency in urination, 
with more or less pain in the act. 

The flow of pus from the urethra becomes diminished, or stops entirely, 
to the delight of the patient, who indulges in the vain hope that that 
part, at least, of his misfortunes at last is over. The relief from ure- 
thral trouble is only transitory, and the discharge will return as the . 
inflammation in the testicle subsides. 

The fever increases at first as the testicle swells, and to the intense 
and increasing pain in the groin is added often an intolerable splitting 
pain in the back, low down. Meantime as the testicle increases in all 
its dimensions, fluid generally collects in the tunica vaginalis, keeping 
the testicle oval in shape. The scrotum gets red and hot, and is some- 
times the seat of a very considerable oedematous effusion. 

The intensity of the symptoms, and the height to which the inflam- 
mation reaches, vary greatly in different cases. There may be nothing 
more than a little tension of the epididymis, the size of a hickory nut, 
most marked posteriorly, lasting only a few days, and totally relieved by 
the recumbent posture, if the testicle be at the same time elevated and VS 
supported. On the other hand, the suffering may be intense, the scrotum ! 
hot, red, and shining, the pain in the groin and back excruciating, the 
tunica vaginalis tense and full of fluid, the substance of the whole testicle 



EPIDIDYMITIS. 99 

seemingly in a state of most active inflammation, and this condition is 
not relieved either by position or by support to the testicle. In such 
severe cases the body of the testicle probably participates in the inflam- 
matory condition (epididymo-orchitis) as well as the tunica vaginalis 
(vaginalitis) and the vas deferens (funiculitis, deferentitis). The swollen 
cord may be felt running up the groin, where it is excessively sensitive 
to pressure. In epididymo-orchitis there is an increase in the testicular 
swelling and a greater amount of serous effusion into the tunica vaginalis ; 
the anatomical boundaries cannot be distinguished and the general swell- 
ing becomes very great. 

First attacks of epididymitis, like first attacks of gonorrhoea, are 
usually much more formidable in their symptoms than subsequent visita- 
tions of the same malady. In the subacute form of epididymitis, espe- 
cially in a testicle which has been the seat of former attacks, the whole 
malady may consist in a hard lump, which appears at the globus minor 
or major, attended by more or less pain, dragging, and constitutional 
symptoms. This lumpiness usually remains long present, perhaps for 
months or even years, becoming finally almost or quite insensitive, and 
not responding at all to medication. 

In the acute cases it generally takes from two days to a week for the 
increase in size of the testicle to reach its height, after which the swell- 
ing goes down — at first slowly, then quite promptly, so that in ten days 
or two weeks, under treatment, it may be counted upon with reasonable 
certainty that the most desperate case will be practically well — that is, 
free from pain to such an extent that it may be supported in a suspensory 
bandage, or at least strapped, and thus the patient be allowed to get about 
in comfort. 

Complications and Sequelae. — Epididymitis may attack the undescended 
testis. The gland may have reached the inguinal canal when its recogni- 
tion is not difficult, or it may not have left the abdominal cavity. In the 
latter instance general peritonitis is a possible result. 

Abscess complicating epididymitis is uncommon except in the case of 
old men with prostatic disease. Its occurrence in the young suggests the 
existence of a tuberculous diathesis. Gangrene of the scrotum is phenom- 
enal. It occurs only in connection with a morbid constitutional disorder, 
such as Bright' s disease or diabetes. 

Atrophy of the testis is reported in a few cases as a sequel to epi- 
didymitis, and hypertrophy is somewhat more common, especially after 
recurrent attacks. If there be atrophy there must have been also orchitis. 
Chronic infiltration of the epididymis often remains behind for an in- 
definite period, and in some individuals this hard focus relapses into a 
J subacute epididymitis from time to time. It is probable in such in- 
stances that there is coexistent chronic inflammation of the seminal 
vesicle or prostate, or both. Chronic hydrocele is also favored by this 



H 



100 VENEREAL DISEASES. 

inflammatory induration, and is not infrequently found as a sequel of 
swelled testicle. 

Neuralgia, amounting to paroxysmal pain or constant acute sensitive- 
ness of the organ itself or in the region of the cord, reflex neuralgic pains, 
sometimes of a very intense character, radiating along the course of the 
lumbar and sacral nerves, are common sequels of epididymitis, especially 
in neurotic subjects and when chronic thickening remains. 

Azoos2jermia occurs as a sequel to bilateral epididymitis, producing 
sterility. An acute attack of the affection, if it passes over within a 
reasonable time, leaves no injury to the epididymis behind it; but the 
subacute attacks — those characterized by localized large nodular de- 
velopments in the tail or head of the epididymis — are apt to fail to 
get entirely well, and as a consequence the convoluted tube constitut- 
ing the epididymis becomes obliterated at the point occupied by the 
nodule, and the passage of spermatozoa through it becomes mechanically 
impossible. 

Inflammation in the epididymis results in plastic exudation. The 
calibre of the tube becomes filled up as the morbid process advances, and 
the connective tissue in which the tubes lie becomes the seat of a similar 
plastic inflammation. This process thickens the whole epididymis by 
new connective-tissue deposits, and fuses together into a solid mass the 
convolutions of the canal of the epididymis. The canal shows irregular 
dilatations and contractions at the seat of the lesion ; caseous degeneration 
may subsequently attack the whole mass, and in cachectic or tuberculous 
subjects tuberculous infiltration may supervene. Gosselin pointed out 
that localized epididymitis of the tail of the testicle was more apt to pro- 
duce sterility than when the head of the epididymis alone was involved 
in the disease, the reason being that many tubes unite to form the globus 
major, while the globus minor is composed of the convolutions of a single 
tube. 

The sterility encountered after gonorrhoeal epididymitis is present 
only when both testicles have been diseased, and not necessarily then. 
This sterility has no connection with impotence. The patient's virile 
powers are as strong as ever, his sexual act is perfect. Yet the fluid ejac- 
ulated is not healthy sperm. It has the spermatic odor but is watery in 
quality, and apparently composed entirely of fluids from the seminal 
vesicles and from the prostatic follicles, and when careful microscopic 
examination has failed to detect any spermatozoa, the patient is necessarily 
sterile, although he is not at all impotent. 

Time may effect a cure in some cases in which absorption of the in- 
flammatory thickening takes place, but usually neither time nor treat- 
ment is of the least avail. 

Many patients, knowing that prolonged chronic epididymitis on both 
sides is liable to entail the loss of the power of procreation, may come to 



EPIDIDYMITIS. 101 

demand an opinion as to their capacity to beget a child. The only- 
grounds upon which such an opinion can be honestly rendered are (pre- 
sumptive) the existence of a lumpy indurated condition of the epididymis 
on both sides, and (positive) the entire and continued absence of sperma- 
tozoa from the spermatic fluid. 

Treatment. — Here, as in all the possible complications of urethritis, 
"an ounce of prevention is worth a pound of cure." A snug suspensory 
bandage should be worn, and all such exercise as might jolt or bruise the 
testicle must be strictly enjoined. The patient should be kept particularly 
quiet during the acute periods of the urethral discharge, and cautioned 
against the least approach to sexual excitement. All those articles of 
food or drink which are known to increase the intensity of the urethral 
inflammation also tend to produce epididymitis, and must be avoided; 
and much care is necessary in the selection of proper injections, as well 
as in the manner of administering the latter. 

The treatment of epididymitis varies somewhat with the grade of 
intensity of the inflammation. During the premonitory twenty-four 
hours, when the principal complaint is of a slight weight or dragging at 
the cord in the groin, with perhaps some discomfort in the testicle and a 
pain in the back, a strong solution of guaiacol, from twenty-five to fifty 
per cent, and sometimes pure guaiacol applied to the scrotum over the 
site of the swelling may produce prompt and marked relief. This remedy 
may be combined with glycerin or vaseline in the above proportion. The 
pain attending an application of pure guaiacol is very intense in most 
cases. Unless under the guaiacol the symptoms shall have abruptly 
subsided, it is proper to put the patient to bed upon his back, to admin- 
ister a brisk laxative, and to sling the testicle well up so that the cord 
may be entirely relieved from its weight, while the return circulation 
from the testicle is favored by gravity. 

This slinging-up of the testicle is a most important matter during all 
stages of the treatment of the malady under consideration. It cannot be 
effected by means of the suspensory bandage. Such a bandage lets the 
testicle drop between the thighs, and, although it is useful in the erect 
posture, it loses its value entirely when the patient lies down. 

An excellent means of suspending the testicles is that employed in 
most hospitals. It is quite effective, but is unfortunately dirty. It con- 
sists simply in cutting a strip of ordinary adhesive plaster, four or five 
inches broad and long enough to stretch from one side to the other over 
the tops of the two thighs, just beneath the scrotum, as the patient is 
lying down. A crescentic piece should be cut out of the plaster to pre- 
vent it from cutting the root of the scrotum. It is applied by being 
fastened securely in place, the adhesive side sticking to the skin on the 
outer aspect of both thighs as they lie close together, the scrotum and in- 
flamed testicle meantime having been drawn well up out of the way, to 



102 



VENEREAL, DISEASES. 



be afterward gently deposited upon the tense, smooth, dry table formed 
between the thighs by the non-adhesive side of the plaster (Fig. 55) . 

The plaster is rather dirty, the legs are constrained, the top of the 
plaster sometimes cuts into the root of the scrotum ; but the bandage does 
not slip, and the support is quite efficient. 

Another method of making support, and one which applies to all 
cases whether or not poultices or other dressings are to be used, is the 
following : a large handkerchief — preferably of silk — is to be folded into 
a triangle. At the centre of the base of this double triangle, opposite 




Fig. 55.— Plaster SMpport for Suspending Testicle In Bed, and Elastic Pressure. 



the right angle, a double piece of tape, about three feet long, is to be 
sewed. An ordinary stiff roller bandage is drawn quite snugly around 
the waist above the flare of the pelvic bones and secured by safety-pins. 
Then the patient is instructed to hold the testicles and scrotum well up 
above and over the symphysis pubis. The centre of the long side of the 
triangular silk handkerchief, marked by the tapes, is now placed in the 
perineum well up against the root of the scrotum, and one end of it is 
carried up on each side along the fold of the groin under the roller band- 
age, after which both these ends are drawn upon so as to make the long 
side of the triangle sufficiently tense under the scrotum, and fastened into 
place with large safety-pins. Finally the two tapes are carried around 
the thighs on either side and under the roller bandage, where they are 
fastened so as to keep the perineal portion of the handkerchief fixed. 
The point of the triangular handkerchief is to be folded over and loosely 



EPIDIDYMITIS. 103 

pinned up to the roller bandage in front, to retain in place any dressing 
which may be put upon the testicle. 

Some authorities advise ice, and its application is very simple. It is 
only necessary to separate the thighs and place the inflamed testicle upon 
a suitable cushion, after which broken ice, floating in its own water con- 
tained in a rubber or oil-silk bag of ample size, is placed upon the testicle 
and cushion. Ice is useful in intense neuralgia of the testicle, but use- 
less if not harmful in most inflammatory conditions. 

By way of internal medication the following combination may be 
given : 

I^ Tinct. Phytolacca decandra, gtt. x.-xxx. 

lodine-vasogen (6 per centj, ..... gtt. xv. 
Given in milk three times daily after meals. 

The former drug is intended to lower arterial tension in the inflamed organ 
and the iodine to assist in the removal of the fluid contents of the tunica 
vaginalis. This special preparation of iodine consists of free iodine in a 
hydrocarbon oil, and is absorbed by the system with marked activity. 

Numerous internal remedies have been at various times advocated in 
the treatment of epididymitis. None of them has held place. The 
contmued nauseant influence of frequently repeated small doses of tartar 
emetic has proved of no value. Pulsatilla has been loudly vaunted, 
splendid effects being claimed for it in doses of one-tenth of a minim 
often repeated up to one drop three times a day. It has failed in most 
hands, employed either to check the pain or to modify the course of the 
malady. It is well to correct the strong tendency to constipation which 
generally exists in the disease by the daily use of gentle laxatives ; and 
on the few occasions when the pains demand it, there is no objection to 
the administration of a small amount of codeine or other gentle anodyne. 

Leeches upon the scrotum do not afford any considerable relief and 
their use is attended by obvious disadvantages. When the testicle seems 
to be strangulated by the intensity of the inflammation, a large number of 
leeches — ten to twenty — placed over the upper part of the scrotum and 
along the course of the cord, will sometimes afford relief from the imme- 
diate and excruciating pain; but puncture of the tunica vaginalis will 
afford similar relief and is to be preferred. 

In all acute cases of epididymitis there is more or less effusion of 
serum into the cavity of the tunica vaginalis, making an acute hydrocele, 
the size of which is sometimes considerable, generally unimportant. 
When the tension within the testicle is great and the effusion consider- 
able, relief may sometimes be promptly afforded the patient by resorting 
to puncture of the tunica vaginalis. A number of punctures may be made 
subcutaneously with a fine, sharp-pointed knife, so that the fluid may 
escape into the meshes of the connective tissue of the scrotum, or the 



104 VENEREAL DISEASES. 

serum may be drawn off by aspiration. After aspiration the cavity may re- 
fill, but often the acuteness of the pain subsides after a single puncture, and 
the subsequent collection of fluid may be disregarded. When the tunic is 
not distended, its puncture does not afford relief — as might be inferred. 

This operation is entirely devoid of any risk or danger, and is justi- 
fiable under all circumstances of distention of the tunica vaginalis in 
connection with acute inflammatory disease. 

The sheet anchor of treatment in epididymitis, however, is the local 
use of hot fomentations or poultices. Belladonna and opium in different 
forms, as hot decoctions and infusions, have been employed, but they 
possess no advantage over tobacco and flaxseed. Tobacco is undoubtedly 
a filthy substance, but it may be so managed that the patient is little, if 
at all, soiled by it. Excoriations of large size upon the skin of the 
scrotum contraindicate the use of any narcotic or anodyne in the poul- 
tices, which must then be composed of some simple material. 

To make a tobacco poultice which shall be at once efficient and clean 
the following course may be followed : one ounce (a paper, as ordinarily 
sold for chewing) of fine-cut tobacco is to be finely shredded into a tin 
or earthen vessel containing from eight to ten ounces of boiling water. 
Into this is put a tablespoonful of glycerin or of sweet oil, and into the 
whole, while being rapidly stirred, is mixed a powder of equal parts of 
ground elm bark and ground flaxseed, in sufficient quantity to bring the 
whole mass to the proper consistence for a soft poultice. Some patients 
manifest disagreeable sensations due to the effect of tobacco absorption, 
in which case the latter should be removed from the poultice. 

Plain flaxseed poultices may also be used in place of the tobacco com- 
bination. 

Whatever is used should be placed between two layers of cheese-cloth, 
and after being put around the testicle, should be surrounded by absorbent 
cotton to help retain the heat, and covered over with a piece of oil silk 
to protect the bed clothmg. 

The poultice when made should be perfectly moist, soft, and smooth, 
but should not drip. It should be large enough to cover the entire tes- 
ticle — indeed, the whole scrotum. It must be applied as hot as it can be 
borne and renewed every one or two hours. 

It is well in all cases bad enough to confine the patient to bed that 
the poultice should be applied at once as soon as the testicle is suspended. 
It often succeeds in relieving the testicle within a few hours and in entire- 
ly o'^ercoming the pain. In all very acute or intense cases, however, this 
effect cannot be expected before the lapse of two or three days, possibly 
longer. 

The vast majority of cases of epididymitis call for no further treat- 
ment during the acute stage than the simple means already enumerated : 
mild laxatives, an elevated position of the testicle with the patient upon 



EPIDIDYMITIS. 



105 



his back, and the continuous use of poultices. Under these means the 
acute symptoms pass off in a period varying from a few hours in mild 
cases to a few days, all pain disappearing at the very outside in two 
weeks in the worst cases. Generally the patient who lies down at once, 
even with a very severe first attack of the disease (which is the worst he 
can have), may be assured that he will be out and attending to his busi- 
ness in ten days, and this period under good management may ®ften be 
shortened to a week, while cases which last only from twenty-four hours 
to three days are by no means uncommon. 

When the acute symptoms subside, however, the patient is not well. 
The pain usually subsides entirely in from one to three, or possibly five 
or six days; but long after the patient ceases to feel pain the swelling 




Fig. 56. 



remains, and the dragging upon the cord by the weight of the testicle in 
the erect position brings on acute pain. It is at this stage that properly 
applied pressure renders distinct service in reducing the swelling and 
lessening the tenderness of the organ. 

Should a patient find it necessary to leave his bed before completing 
his week or ten days, and not be able to wait until he can stand erect for 
fifteen minutes without pain, he may do so by the aid of strapping or 
elastic compression. Just as soon as the acute symptoms are fairly on 
the decline and the testicle can be handled, even although it be with 
pain, the patient may get up and go about with safety, so far as relapse 
is concerned, if the testicle be properly strapped. The first straps should 
be put on with great gentleness and not too tightly. The patient must 
be directed to stay in bed, and to remove the straps or to cut them down 
the front, if the testicle be not quite comfortable in half an hour after 
the straps have been applied. 

The straps composed of rubber plaster are required to be carefully 
applied and sometimes cause trouble in being removed, it being necessary 
to soak them off in hot water if the plaster is very adherent. Another 
method of obtaining the benefit of compression of the swollen testicle after 
the tenderness has subsided, and one which is equally satisfactory and 
much less troublesome, is elastic pressure procured with a section of a 
rubber elastic bandage about three inches wide and six to seven inches 
long. Attached to one end of this is a narrow strip of rubber adhesive 
plaster about one-half inch wide and long enough to go once around the 



106 VENEREAL DISEASES. 

testicle and overlap. This plaster is intended to hold the rubber bandage in 
place after it has been applied (Fig. 56) . This is accomplished as follows : 
The swollen testicle is pulled down slightly and the sound one is pushed 
upward against its ring ; the free end of the rubber bandage is applied to 
the surface of the organ and the rest is used to encircle it, being applied 
with sufficient tension to procure moderate pressure. The bandage is 
finally held in place by wrapping around it the rubber adhesive strip 
(Fig. 55). The even elastic pressure thus attained acts most promptly 
upon the swelling and never produces any trouble. The bandage 
tends to contract with the testicle, and may be readjusted when neces- 
sary. By the use of such means of compression the acute stage of the 
attack is liable to be shortened and the patient likely to get about sooner 
than without this expedient. In cases in which the testicle will stand 
the pressure without undue pain, it may be applied while the patient is 
still confined to bed, in conjunction with the poultices, and thus curtail the 
duration of the attack. 

Chronic relapsing epididymitis may be treated by vasectomy (ligation 
of the vas deferens) on the affected side. The authors have performed 
this operation m a number of instances, with the result of a permanent 
cure in every case. One case was bilateral and had double hydrocele. 

The operation is simple, and may be done over the external ring or 
in the median raphe of the scrotum ; in either of which locations the cord 
is readily found, the vas deferens separated, and a small piece, about 
one-fourth of an inch, resected between two ligatures. 



CHAPTER VI. 

STRICTUKE OF THE UBETHRA. 

A COMMON COD sequence of gonorrhoea iu the male is stricture of the 
urethra. True stricture, a narrowing of the calibre nf the canal, the 
result of inflammatory exudation and cicatricial contraction, also may be 
due to other causes, such as traumatic violence of any sorO, mechanical or 
chemical. Congenital imperfection of the urethra, more common at the 
meatus, producing a constriction of the canal, has been called " congenital 
stricture.'^ It differs from true stricture in that it does not contract, but 
remains as congenitally formed. It therefore might be termed for dis- 
tinction congenital stenosis. The term "acquired strictui^e^^ embraces 
the various other forms, such as organic, traumatic, spasmodic, and in- 
flammatory. Organic stricture occurs as a result of acute inflammation 
of or injury to the canal, and represents what is meant by true stricture. 

Traumatic stricture is included in the previous classification, but is 
of non-venereal origin. 

The term " inflammatory stricture " denotes a constriction produced 
by soft inflammatory cellular infiltration, which may be absorbed or may 
go on to form true fibrotic stricture. It also signifies simple inflamma- 
tory, oedematous, and congestive swelling enough to diminish the cali- 
bre of the canal. This is in no sense a true stricture. 

Spasmodic Strictuke. 

" Spasmodic stricture " may depend upon a multitude of causes, gen- 
eral as well as local, morcil as veil as physical. Moreover, it may com- 
plicate the other forms of stricture of the canal and give to them an im- 
portance which they would net otherwise possess. Spasmodic action of 
the musclos of the deep urethra produces an obstruction which may result 
in retention of urine ; but as the cause may exist outside the urethra, being 
reflex, and as this condition sometimes coexists with true stricture, it is 
more properly designated urethral spasrm. 

Urethral spasm or " spasmodic stricture " is generally capable of very 
easy demonstration. A personal case will well illustrate this. 

A young man, under twenty years of age and perfectly healthy so 
far as urethral or antecedent venereal disease of any kind was concerned, 
finding some pediculi upon hie pubes, was kindly suppl^'ed with a lotion 
by an obliging friend with which to kill them. This ho applied faithfully 



108 VENEREAL DISEASES. 

in the morning. The lotion, which was a simple tincture of delphinium, 
proved quite irritating, and presently occasioned much tingling and 
burning of the skin where it had been applied, and brought on a desire 
to urinate ; but the patient, to his surprise, found that he could not void 
a drop of urine, the bladder being only slightly distended. 

He continued up and about all day, making repeated but absolutely 
futile efforts to empty his bladder, and finally sought relief late in the 
afternoon, when a full-sized olivary soft catheter was readily passed into 
the bladder, encountering no obstacle, and a clear, bright stream of urine 
gushed out in torrents through the instrument to the amount of more 
than a pint. 

The patient passed water voluntarily in the evening before retiring, 
and has had no further trouble. 

This case was certainly one of spasmodic contraction of the muscles 
of the deep urethra, due to irritation reflected from the skin. There was 
no present or past malady of the bladder or urethra, and has been none 
since. Efforts were made in vain by the patient to empty his bladder 
during all stages of fulness. There was not a particle of atony in the 
case, for, as soon as the urine found a hole from which to escape, it 
gushed forth under the powerful contraction of the detrusor, and did 
not dribble away sluggishly from the end of the catheter, as it is wont to 
do in cases of atony, unless aided by the efforts of the abdominal muscles. 
The stream in this case continued with equal force and vigor up to the 
last few drops. Here, then, is a case of pure reflex spasm of the urethra. 

In February, 1896, a patient called upon the authors, having had sev- 
eral attacks of complete retention of urine. He had reached the age for 
prostatic hypertrophy, and had been told that such was the cause of his 
trouble. Indeed he had just come away from a Brooklyn hospital because 
orchidectomy had been proposed, which he had rejected. Examination 
revealed that there was no undue frequency of urination by day, nor even 
at night ; that the bladder emptied itself completely, and that each attack 
of retention had been relieved instantaneously by the single passage of a 
catheter, and was separated by a long interval from each previous attack. 
Exploration of the urethra demonstrated the existence of a true organic 
stricture, but one which was quite permeable. The prostate was practi- 
cally normal. The retention of urine had been caused by spasmodic 
contraction of the deep urethral muscles- -urethral spasm — complicating 
true organic stricture. 

Tuffnell reports a case in which a patient had a stricture deemed im- 
passable (doubtless because fine bougies only were used in attempts to pass 
it). This patient suffered so much that a day was appointed upon which 
perineal section should be performed; but before the date arrived he 
passed some links of tapeworm, unsuspected before, and, as a part of 
the preparation for his operation, a medicine was given to dislodge 
the worm. This proved successful. The worm was passed, and with it 



STRICTURE OF THE URETHRA. 109 

the impassable stricture disappeared, and the patient urinated freely at 
will. 

It has occurred several times in our experience for a surgeon to 
make a diagnosis of tight stricture in a given case, and to find his fili- 
form bougie — which he has passed with difficulty — grasped, as he 
attempted to withdraw it, when there has been nothing more in the case 
than spasmodic contraction of the deep urethra, as proved by the fact 
that a well-warmed, large, blunt steel sound, held gently against the face 
of the obstacle, has after a short delay, slipped, by its own weight, 
smoothly into the bladder. 

Regarding the location of urethral spasm it is probably found only in 
the membranous portion; and although some authors have claimed its 
existence in the anterior canal, Guyon has demonstrated by the applica- 
tion of the electric current that no spasmodic contraction of this region 
occurs. In some cases it is quite difficult to distinguish between urethral 
spasm and a stricture situated at the bulbo-membranous junction. The 
resistance of the latter is firm, tense, abrupt, as contrasted with the mus- 
cular contraction which is softer, more yielding, and elastic. 

If a blunt steel instrument be held firmly against the face of a " spas- 
modic stricture " with gentle but persistent pressure, the contraction often 
yields suddenly and the instrument enters, causing a certain amount of 
pain ; but in the case of true stricture the resistance is firm and unjaeld- 
ing, and is not suddenly overcome by the gentle force of an instrument 
larger than the calibre of the stricture. 

The attendant symptoms will render additional assistance in dis- 
tinguishing between these two conditions. In the case of urethral 
spasm the evidence of urinary obstruction is of an irregular character. 
Sometimes the difficulty lies at the commencement of urination, while the 
continuation of the act is normal. Again, an effort is required to pass the 
water during the entire act, or the stream may be abruptly interrupted 
before the bladder is emptied ; while in other cases partial or complete 
retention may occur. The presence of urethral spasm is clearly demon- 
strated when the functional difficulty is not constant but variable, and 
an attempt to pass a small bougie is unsuccessful. An organic obstacle, 
if small enough to obstruct the bougie, would yield constant symptoms. 
When even the smallest instrument will not pass in the case of spasm, a 
very large blunt steel sound will sometimes enter without hesitation or 
delay. 

The causes of urethral spasm are direct and indirect. Who is un- 
familiar with the effect of shame, haste, anxiety, anger, nervous ex- 
citability, and other emotions in making it absolutely impossible for a 
perfectly healthy patient sometimes to void water at all for a consider- 
able time? Such retention is due to a spasm of the urethra. Of the 
various local causes of " spasmodic stricture '' may be mentioned cystitis 



110 VENEREAL DISEASES. 

of the neck of the bladder, posterior urethritis, stone in the bladder, 
irritation about the rectum, and trouble in the anterior urethra, acute 
inflammation, organic stricture, and contracted meatus. The grasping 
of a sound by an organic stricture, through which the instrument has 
been passed, is due to spasm. The lack of co-ordination between 
the detrusor and the cut-off muscles, often leading to retention in 
cases of locomotor ataxia and partial paraplegia (especially syphilitic), 
acts apparently by causing spasm of the deep urethral muscles. The 
different conditions in which deep organic stricture habitually finds itself 
— sometimes allowing a reasonably free stream of urine to pass, again so 
nearly closed up that only a few drops can be painfully voided with great 
effort — are undoubtedly due more often to spasm than to any purely in- 
flammatory change in the stricture itself. That form of partial or com- 
plete retention sometimes seen in connection with a very slight stricture of 
large calibre, either in the deep or in the pendulous urethra, is certainly 
due to spasm of the membranous sphincter, as proved by the ease with 
which many of these cases allow the passage of a large-.sized steel in- 
strument without the employment of any force. 

Treatment. — The surgeon's tact and ability are often taxed to dis- 
cover the cause of deep urethral irritability and spasm. To be successful 
in his treatment he must find the cause ; when that is removed the " stric- 
ture " will get well. The cause may lie in a tight meatus, or in an irri- 
table anterior or posterior stricture of large or small calibre, which will 
require appropriate treatment. 

Sometimes the passage of a large-size catheter or a well-oiled sound 
will result in the instant relief of the difficulty, and the same result may 
be brought about by means of a hot sitz-bath. 

Organic Stricture. 

Etiology and Location. — ^Most cases of organic stricture owe their 
origin to gonorrhoea, and it is that form which is commonly referred to 
in speaking of stricture of the urethra. Injury to the urethra resulting 
in complete rupture of the canal, or lacerations and abrasions of a lesser 
degree, blows or falls upon the perineum, forcible bending of the penis 
during erection, may all be followed by the production of organic 
stricture. 

When stricture of the urethra results from gonorrhoea it is due rather 
to a long-continued inflammatory process than to an inflammation intense 
in character but short in duration. The development of stricture is 
generally slow. It is seldom encountered much before the second year 
following gonorrhoea, although there are marked exceptions. The gro^^th 
of stricture is also dependent upon the nature of the original lesion. In 
traumatic stricture the period is shorter than that following inflammation 



STRICTURE OF THE URETHRA. Ill 

of the canal. Sir Henry Thompson, from an observation of 164 cases, 
found that about one-sixteenth of this number had developed in less than 
one year from the urethritis, about three-fourths of this number between 
one and four years afterward, and that the balance was equally divided 
between periods of seven and eight years and over twenty years. ^ Guy on 
finds from an observation of 142 cases the following order of frequency : 
During the first year, 4 ; from first to second year, 10 ; second to fourth 
year, 20; fourth to sixth year, 19; sixth to eighth year, 24; eighth 
to tenth year, 16 ; tenth to fifteenth year, 49. Thus it appears that in 
a majority of instances stricture in his experience is detected between two 
and ten years after the original inflammation. 

Stricture may occur at any age, is seldom found in very old men, and 
is most common between the ages of thirty and forty. 

Regarding the most common location of stricture Taylor,^ in a classi- 
fication of 250 personal cases, finds 62 per cent in the sinus of the bulb, 
20 per cent in the middle of the pendulous urethra, and 18 per cent in 
front of the latter region. These may be designated regions one, two, 
and three, from behind forward. 

Taylor's tabulation is simply a ratification of Sir Henry Thompson's 
observations. Thus it may be roughly stated that over sixty per cent of 
cases of stricture exist in the region 1}' ing between the bulbo-membranous 
junction and the peno-scrotal angle, and that the remaining cases are 
about equally distributed throughout the rest of the anterior canal. 

Stricture of the prostatic urethra does not occur as a result of gonor- 
rhoeal inflammation. The best observers also state that stricture of the 
membranous urethra does not occur from the same cause, but that this 
portion of the canal is more apt to be dilated, as well as the prostatic 
portion behind an organic stricture involving the section of the urethra 
anterior to them. 

In examining the urethra according to the divisions specified, it has 
been found by many observers that in the majority of cases only one 
region is involved. In some instances the stricture invades the two re- 
gions in front of the peno-scrotal angle (Fig. 57) or the two consecutive 
regions between the bulbo-membranous junction and a point two and 
one-half inches from the meatus, but only exceptionally does stricture 
occur near the meatus in conjunction with stricture in the bulbous 
urethra without involving the intermediate portion. Such records seem 
to show that a single stricture is the rule and that multiple stricture is 
the exception. Other observers claim the opposite of this rule ; but with 
the present knowledge of the pathological formation of stricture tissue, 
it can be understood how in exploring the urethra the conclusion that 
multiple stricture existed might be reached, from the fact that an exten- 

' Desnos : "Traits elementaire des Maladies des Voies urinaires." 
2 "Venereal Disease," 1895. 



112 



VENEREAL DISEASES. 



sive area infiltrated with fibrous tissue must vary at different points in 
the degree of the existing stenosis (Fig. 57) . In other words, a stricture 
commencing in any part of the spongy urethra may reach the maximum 




Fig. 57. — Annular Stricture of the Anterior 
Urethra covering an Extensive Area. 



Fig. 58.— Linear Stricture. 



degree of contraction at the bulbo-membranous junction ; or, on the other 
hand, on account of an increase of deposit of cicatricial tissue at one or 
more points anterior to the bulb, the exploring instrument would detect 
what seemed to be more than one strictured point. 



STRICTURE OF THE URETHRA. 



113 



The formation of stricture is variable, and depends upon the character 
and extent of the pathological changes in the course of the canal. Thus, 
when there exists an infiltration of the connective tissue sufficiently dense 
to cause a stenosis of the calibre, but before fibrous tissue has been 
formed, such a condition 
is spoken of as soft strict- 
ure. When the fibrous 
element has sufficiently 
invaded the softer struct- 
ure at the further expense 
of the normal tissue, the 
lesion is called a semi- 
fibrous 01 fi,brous stricture 
according to the degree 
of thickening. Finally, 
when this process ex- 
tends itself still farther 
so that the normal tissues 
are entirely obliterated 
and sclerotic and atrophic 
changes occur, yielding a 
firm and indurated 
structure, the so-called 
inodular stricture is the 
result. 

These pathological 
changes, as they involve 
greater or less areas of the 
canal, and are accompa- 
nied by more or less ste- 
nosis in different portions, 
represent the various 
types of stricture under 
the different clinical ap- 
pellations. Thus a linear 
stricture is a band of 
fibrous thickening with a 
maximum narrowing at 
one point (Fig. 58); an- 
nular stricture, the same 

condition covering a broader surface, sometimes involving several inches 
of the canal (Fig. 57), while an extensive distribution of the nodular tissue 
around an irregular channel results in what is called inodular or tortuous 
stricture (Fig. 59). 
8 




Fig. 59.— Inodular or Tortuous Stricture. 



114 VENEREAL, DISEASES. 

For purposes of classification it is customary also to divide strictures 
with regard to the degree of stenosis into strictures of large and small 
calibre. Such a distinction is of course simply an arbitrary one and is 
governed by no established standard. It is generally understood that a 
stricture which will permit the introduction of an instrument 5 mm. in 
diameter (15 French) or larger may be considered one of large calibre, 
while anythmg below this is regarded as of small calibration. 

In order to determine whether or not the urethra is the seat of a nar- 
rowing such as should properly come under the title of stricture it is bet- 
ter to have in mind a popular standard for the normal urethra to compare 
with. Any pronounced variation below the natural calibre must be con- 
sidered a "stricture of the urethra." It is important, however, in deter- 
mining the natural calibre of the urethra to bear in mind that there 
normally exist anatomical points of narrowing, and that between these 
anatomical points the urethra may be dilated beyond what should be 
regarded as its normal calibre (Fig. 60). 

The objection to the division of strictures into those of small and 
large calibre is that unless the standard be placed at a reasonable size 
strictures of large calibre will undoubtedly oftentimes be discovered at 
one of the points of physiological narrowing. The objection is properly 
raised to the scale given by Otis, which recognizes a definite relation be- 
tween the circumference of the penis and the calibre of the urethra, that 
it is too dogmatic and represents more accurately the distensibility of 
the urethra than its normal calibre. 

The scale adopted by Otis is shown in the following table :^ 

Table Showing the Relative Circumference of the Penis and Urethra. 





Circumference 


Circumference 


circumference 


Circumference 




of Penis, 


of Urethra. 


of Penis. 


of Urethra. 


3 


inches, or 43 mm. 


30 mm. 


3f inches, or 93 mm. 


36 mm. 


3i 


" " 81 " 


32 " 


4 " " 100 " 


38 « 


3i 


>> (( Q'J t( 


34 " 


4^ to 4^ inches, or 106 to 
112 mm 


40 " 



In employing the above scale for estimating the normal calibre of the 
urethra Dr. Otis has devised and recommends the urethrometer, an in- 
strument for exploratory purposes, having a hinged extremity which can 
be expanded to a bulbous shape between sizes 20 and 45 French (Fig. 
66, p. 121), but when any urethra is explored with this instrument and in 
accordance with the above table it is hardly possible that it will be found 
free from some variation in its calibre and therefore will be considered as 
the seat of stricture, a conclusion the acceptance of which must lead to a 
most indiscriminate and unnecessary interference either by cutting or by 
overdistention. A conservative estimate of the average size of the canal 
in the majority of cases places the normal calibre at about 28 or 30 French, 

I Otis : " Stricture of the Urethra." 



STRICTURE OF THE URETHRA. 



115 



and while exceptionally it may be somewhat above or below such a stand- 
ard, the greatest satisfaction has been attained by those observers whose 
experience permits them to express an authoritative opinion in the accept- 
ance of this standard both for exploring the urethra and in the treatment 
of stricture. 

The meatus externally and inside the orifice is the most commonly 
constricted point and is subject to considerable variation. It is here that 
congenital narrowing is so prone to exist that it has led to the expression 
of "congenital stricture." The 
meatus is sometimes found 
sealed up to the size of a pin- 
head, livid in color and conical 
in shape, manifestly unnatural, 
and from this size upward it is 
found of all sizes, sometimes 
altogether disproportionately 
large as compared with the rest 
of the canal. This smallness, 
which is a congenital deformity 
and not a pathological condition, 
never calls for interference on 
the part of the surgeon unless it 
be presumed to be the probable 
cause of symptoms such as re- 
flex spasm of the membranous 
sphincter, or unless it interferes 
by its smallness of size with the 
proper treatment by instruments 
of morbid conditions more 
deeply seated. About the middle of the spongy portion, from two 
to three inches from the meatus, there exists in a large percentage of 
individuals another point of physiological narrowing which is often des- 
ignated a stricture of large calibre by those who examine the urethra 
according to the scale of Otis and with the idea that it should possess a 
uniform calibre throughout its whole course. Behind the structured mea- 
tus we have a dilated area known as the fossa navicularis. Another 
dilated cul-de-sac exists in the sinus of the bulb, in front of the triangu- 
lar ligament, the location of which is readily recognized by the introduc- 
tion and withdrawal of an instrument, especially a bulbous bougie, and at 
the triangular ligament- is another point of physiological narrowing which 
should not be mistaken for stricture. Besides these common points of 
constriction and dilatation throughout the course of the pendulous ure- 
thra there undoubtedly exist many other variations from the maximum 
and minimum calibre, so that in exploring the urethra the larger the 




Fig. 60.— a Portion of a Normal Urethra Distended 
with Air, showing Transverse Bands. 



116 VENEREAL DISEASES. 

instrument the more bands does it discover along the course of the canal 
(Fig. 60). Such points simply represent areas of uneven dilatability and 
will exist whether such an individual possesses a healthy urethra or is 
the subject of real stricture 5 whether he has suffered from no symptoms 
or has had gleet; whether his urethra has been cut internally or not, and 
whether or not his symptoms have yielded to treatment. Consequently 
the existence of these areas in the anterior portion of the urethra does not 
constitute stricture, and stricture may be cured while the areas still re- 
main behind. 

When gonurrhoeal stricture occurs it has been pointed out by patho- 
logical observers that it generally involves the urethra over a large area; 
that there may be points at which exist greater degrees of contraction 
than others representing several of the transverse folds which have be- 
come infiltrated and consequently impinge on the calibre of the canal to 
a greater extent than the intervening portions. Such points are simply 
parts of the same lesion and should not properly be counted as separate 
strictures. 

Traumatic strictures are generally limited in area and localized in one 
region, according to the seat of the injury, which is more commonly in 
the bulbous portion. 

Cicatricial contraction due to chancre or chancroid usually is found 
near the meatus. 

Symptoms. 

« 
Strictures of wide calibre may give rise to spasmodic and irritable 

troubles in the deep urethra. When they do so act, however, they are 

themselves generally more or less sensitive and inflamed. Sometimes, 

on the other hand, especially at the meatus, such strictures are neither 

inflamed nor sensitive, and it becomes a doubtful question to decide 

whether they have anything to do with troubles deeper in the canal or 

not. 

The vast majority of these strictures produce no symptoms whatso- 
ever, excepting a slight gleet, and some of them not even that. Before 
deciding that a given tight spot in the urethra is the cause of other trou- 
ble deeper in the canal, it is wise to eliminate all other sources of such 
trouble, and not to jump at the conclusion that because there are bands 
in the urethra, and spasmodic or inflammatory trouble farther down, the 
latter necessarily depends upon the former, and will be relieved by a 
cutting operation. Such a doctrine must certainly sooner or later lead the 
young practitioner to the border-line of quackery, if not into its domain. 

The most common symptom of strictures of large calibre in the pen- 
dulous or in the deep urethra, is a gleety discharge more or less purulent. 

As stated above, stricture of large calibre may go for a long time un- 
discovered. Being of gonorrhoeal origin its formation is usually slow. 



STRICTURE OF THE URETHRA. 117 

As the strictured area contracts, the patient may become accustomed 
unconsciously to the slight effort involved during the act of urination 
and may fail to recognize any alteration from the normal state. A 
period is sooner or later reached when the patient becomes conscious of 
some modification either in the size or the shape of the urinary stream. 
This may be twisted or it may be uniformly small or flattened or may be 
expelled in two separate jets. Such changes in the volume and form of 
the stream are not invariably significant of the existence of true stricture, 
as they may be noted in acute and chronic urethritis, in prostatitis, and 
in urethral spasm, when the real calibre of the canal is determined by ex- 
ploration and found to be normal. 

Of much greater importance is the projectile force of the stream dur- 
ing the act of urination as an index of the tone of the bladder muscle ; 
but even when there exists a marked contraction of the urethra due to 
stricture, the bladder having become reinforced by compensatory muscu- 
lar hypertrophy may eject the stream from the urethra with reasonable 
force. Soon, however, the bladder becomes unable to compensate for the 
obstruction in the canal, the stream is not only much diminished in size 
but ceases to be projected to any distance from the end of the penis and 
either falls perpendicularly in a small stream or is voided by drops after 
considerable effort on the part of the patient. These symptoms denote 
tight organic stricture, and in this condition, as a result of catching cold 
or from the effect of instrumental examination, congestion of the surface 
of the stricture or reflex spasm of the compressor urethree muscle is pro- 
duced, from either of which causes the passage of the urethra becomes 
occluded and urinary retention occurs. 

Urethral discharge, which is one of the earliest symptoms, more or 
less muco-purulent in character, is generally found in all cases of stricture 
of small calibre, but it may be entirely absent. The quantity of the se- 
cretion is generally scant, sometimes rather free. It is more commonly a 
morning drop but may also occur during the day. A free discharge is the 
exception rather than the rule, and the pus which is formed at the in- 
flamed and congested area in connection with any stricture may simply 
appear in the urine in the form of shreds and masses. 

There may exist a certain amount of uneasiness and smarting during 
urination in connection with strictures, but such subjective symptoms 
may be entirely absent. 

Increased frequency and urgency of urination may be due to posterior 
urethritis or urethro-cystitis. 

Strictures in any part of the urethra may be attended by pain felt 
either at the point where the stricture is located or referred to the meatus 
or to some other portion of the canal. Frequency of urination is much 
more marked when the deeper regions are involved, such urinary fre- 
quency being relatively greater by day than by night. Epididymitis, 



118 



VENEREAL DISEASES. 



sometimes acute and sometimes mild and relapsing, occurs in connection 
with strictures, notably those which are irritable, inflamed, or of small 
calibre and so situated as to affect the deeper portion of the urethra and 
the vesical neck. Retention of urine occurs with variable frequency. 
While it is more liable to complicate stricture involving the deeper 
regions, it may occur as a result of reflex spasm in connection with stric- 
ture in the anterior portion. Some patients are much more liable to be 
attacked by this symptom than others, especially those of a neurotic tem- 
perament, although anything which is likely to cause hyperaemia of the 
mucous membrane overlying the compressor urethras muscle, such as cold 
or the passage of instruments, may be the means of provoking this com- 
plication. 

The ultimate result of long-continued tight stricture is generally 
chronic inflammation of the' bladder attended by thickening of the vesical 
wall, contraction of its cavity with contracture or sometimes dilatation 
and atony, resulting perhaps in constant dribbling of urine due to over- 
flow of the distended organ and loss of power of the vesical and mem- 
branous sphincters. 

Finally, as the result of tight stricture extends itself upward, dilata- 
tion of the ureter and pelvis of the kidney and pyelonephritis are brought 
about, which may lead at any time to a fatal issue by an attack of acute 
uraemia, or after a long duration to a slowly progressive condition of kid- 
ney insufficiency. 

Diagnosis. 

The physical examination of the urethra is conducted by means of 
bougies of various kinds and solid steel sounds. These instruments are 
graded as to size in accordance with the different scales of measurement 
commonly in use, known as the French, English, and American. The 
relative sizes of these scales are shown in the accompanying table : 

Table op the Approximate Relations Between the English, American, and 

French Scales. 



English. 


American. 


French. 


English. 


American. 


French. 


1 


3 


5 


12 


14 


21 


2 


4 


6 


13 


15 


23 


3 


5 


7 


14 


16 


24 


4 


6 


9 


15 


17 


26 


5 


7 


10 


16 


18 


27 


6 


8 


12 


17 


19 


29 


7 


9 


14 


18 


20 


30 


8 


10 


15 


19 


21 


32 


9 


11 


17 


20 


22 


33 


10 


12 


18 


21 


23 


35 


11 


13 


20 


22 


24 


36 



The metal steel sounds (Figs. 61, 62) are blunt or conical at the extrem- 



STRICTURE OF THE URETHRA. 



119 



ity. The former are used for diagnostic purposes, the latter for dilata- 
tion. The reason for this is obvious. 
The shoulder of a blunt instrument can 
more readily detect the presence and 
the nature of the urethral obstruction, 
while the tapered sound can be more 
readily engaged in a narrowing of the 
canal and is better for dilating purposes. 
We are accustomed to employ in dilating 
the urethra a sound which is tapered in 
both directions, toward the handle as 
well as toward the extremity, the object 
of which is to avoid the continued disten- 
tion of the meatus, especially when this 
part is constricted, while the deeper por- 
tion of the canal is being subjected to the 
required amount of distention (Fig. 67, 
p. 126). 

Acorn-shaped bulbous bougies, the 
bougie a boule (Fig. 63), which are con- 
structed of metal or flexible rubber, are 
preferable to the sound for exploring the 
anterior urethra. They readily detect the 
presence of strictured areas in entering 
the canal and upon withdrawal will carry 
upon the shoulder a drop of pus or blood 
as evidence of the inflamed area behind 
the strictured portion. 

Flexible gum elastic olivary bougies 
(Fig. 64) may be used both for diagnostic 
purposes and also for dilatation. 

Filiform whalebone bougies (Fig. 65) 
are very delicate whiplike instruments with straight and corkscrew ends 




Fig. ui. — Blunt 
Steel Sound. 



Fig. 63. — Conical 
Steel Sound. 




Fig. 63.— Flexible Bulbous Bougie. 



120 



VENEREAL DISEASES. 



^ 



/ 






used for the purpose of finding tlie orifice of strictures of very small 
calibre wMcli are impermeable to any of the larger-sized exploring in- 
struments, and having passed through the stricture into the bladder are 
employed as a guide upon which the tunnelled sound or catheter is passed 
either for the purpose of dilatation or to serve as a guide 
in incising the urethra through the perineum. Sometimes 
a number of these small filiform bougies are packed to- 
gether in the urethra and then alternately manipulated 
until one shall have engaged and passed the obstacle (Fig. 
69, p. 131). 

By means of the endoscope or urethroscope the urethra 
may be inspected and the character and extent of a strict- 
ured area observed. "While such means are useful and in- 
structive for the purposes of study and scientific obser- 
vation, from a practical standpoint the ordinary urethral 
exploring instruments are more useful for diagnostic pur- 
poses. 

When a stricture of large calibre is important enough 
to yield any symptom besides the possible spasmodic 
and reflex irritative phenomena referred to and the 
gleety discharge, there are certain physical means of 
diagnosis which yield satisfactory results. 

The physical diagnosis of stricture of large cali- 
bre is generally easy. A bulbous bougie (Fig. 
63), metal or gum elastic, as large as the meatus 
will take, may be warmed, lubricated, and gently 
passed through the urethra. When it comes to a 
tight spot the surgeon can feel it as well as the pa- 
tient, and when it is withdrawn the resistance is 
marked and the fibrous character of the tissue ap- 
preciated. If this spot be the seat of the gleety 
discharge, the bulb of the instrument is very often 
faintly tinged with blood at its tip upon with- 
drawal. Points of stricture are often sensitive; 
their length may be measured by the aid of this 
bulbous instrument and their number ascertained if 
more than one exist. This exploration refers only 
to the pendulous urethra. 

It is important to make a separate exploration 
of the anterior and posterior sections of the canal, 
and reach a conclusion as clear as possible regard- 
ing the front urethra before invading the posterior portion of the canal. 

If, on attempting this exploration, congenital or pathological narrow- 
ing of the orifice of the urethra be found to exist, the canal may still be 



/ 



Fig. 64.— 
Flexible 
Olivary- 
Bougie. 



Fig. 65. 

—Filiform 

Bougies. 



STRICTURE OF THE URETHRA. 121 

explored without cutting the meatus by the use of the expanding ure- 
thrameter (Fig. 66) devised by Dr. Otis. This instrument is intro- 
duced closed, capped with a piece of thin rubber, down to the sinus of the 
bulb. It is there to be expanded until the patient feels a slight disten- 
tion, and then to be slowly withdrawn toward the meatus. Upon en- 




countering resistance the handle is turned so as to make the size of the 
bulb smaller, all changes in the bulb being marked upon an index-plate 
at the handle. The shaft of the instrument is marked in inches, and by 
its aid all constrictions in the canal may be located, measured, and cali- 
brated. 

In short, exploration by this instrument leaves nothing to desire, ex- 
cepting a point of departurp. Here, unfortunately, it fails, for it has to 
assume either that the size of some portion of the canal is the natural 
size of the whole course of the urethra (which is manifestly inaccurate, 
as as been shown), or the surgeon has to assume some arbitrary dimension 
as being the proper size of the urethral canal. 

Moreover, with this instrument, damage is apt to be inflicted upon a 
sensitive urethra, which may and often does lead to an aggravation of all 
the symptoms for which the exploration was made, and to the lighting up 
of new ones. This instrument does excellent service at times, mainly in 
the way of accurately locating strictures in the pendulous urethra, which 
the surgeon has decided should be cut. 

When, therefore, the meatus is small and the urethra has to be ex- 
plored, the stricture of the meatus, and any tight spot within the first 
three-quarters of an inch from the meatus, may be cut at once as a part 
of the examination. If the meatus alone is involved, it may be cut down 
to the bottom of any pouch lying behind either of its angles, and 
fully two sizes (American scale) larger, for in healing it will contract 
somewhat, and it should be left so that when well it may be at least 
physiologically large. Any band smaller than the new cut meatus 
and lying near it should also be cut at the same sitting, as part of the 
examination. 

This course is advised for several reasons. First, the urethra cannot 
be properly explored from before backward with a bulbous bougie, unless 
the orifice of the urethra will admit the passage of a fair-sized bulb and 
no organic stricture deeper seated can be treated with sufficiently large 
instruments unless the meatus is prepared for their reception. 



122 VENEREAL DISEASES. 

The operation itself is trivial in importance, and never, when per- 
formed upon a urethra which would tolerate any interference whatever or 
was lit for any examination, has given rise to any complication or subse- 
quent discomfort. The use of the sound upon the deep urethra after 
cutting the meatus is inadvisable, and may lead to disagreeable compli- 
cations — cystitis, posterior urethritis, urethral chill. 

The meatus then should be cut a little larger than full size, and the 
bulb, then introduced as through a natural meatus, will detect strictures 
in the pendulous urethra, if there be any. 

Stricture of large calibre of the bulbo-membranous junction may be 
sought for with a blunt (not a conical), well-warmed steel sound, of a 
size as large as the anterior urethra will admit; and it is sometimes diffi- 
cult to distinguish between true stricture and spasm. If there be spas- 
modic stricture, such an instrument will generally go in if properly 
handled. 

The blunt sound, well warmed and lubricated, should be gently car- 
ried down the urethra and its beak presented accurately at the hole in 
the triangular ligament. Here it should be held under even pressure — 
rather firm, but not violent — a perfectly uniform pressure and with a very 
steady hand, for several minutes if need be. The patient meantime 
should be entertained and diverted, the scrotum being held well up by 
the unemployed hand, which at the same time steadies the beak and the 
curve of the instrument through the perineum. If under such a man- 
oeuvre the sound does not presently slip along and glide smoothly and 
rather swiftly into the bladder, especially if under cocaine or general an- 
aesthesia, it may be either because the stricture is not spasmodic, or be- 
cause the beak of the instrument has not been properly brought to bear 
upon the cramped muscles. 

The diagnosis of stricture of small calibre is more easily made than 
that of stricture of large calibre. 

Congenital constriction of the meatus, external or internal, may be 
readily seen or detected by instruments. The existence of a tight area 
along the pendulous urethra is discovered without difficulty. Sometimes 
it may be felt upon the exploring instrument, and often when composed 
of inodular tissue it may be felt from the outside. It is well to begin 
with an instrument of medium size and carefully note the depth at which 
its further entrance is obstructed, and then by carefully going down the 
scale the correct size of the calibre of the stricture may be determined. 
In the same manner when several contracted areas exist they can be 
detected, located, and measured. 

In exploring the deeper portion of the canal a blunt, curved steel 
instrument should be employed, and the size gradually diminished until 
one which will pass the constricted area is found. Very small steel in- 
struments, unless deftly handled, are dangerous and may cause false 



STRICTURE OF THE URETHRA. 123 

passages in the canal ; and therefore if the apparent size of the stricture 
calls for the use of a very small instrument, it is better to employ gum 
elastic olivary bougies, which will serve the same purpose and are less 
dangerous. 

When the point of narrowing is contracted sufficiently to oppose 
the entrance of even the olivary instruments, after the question of 
spasm has been considered and eliminated, it may be necessary to resort 
to the filiform bougie; and having engaged one of these small instru- 
ments in the mouth of the stricture, it is sometimes possible to gain an 
entrance with a bougie several sizes larger. Nothing need be added to 
what has already been said concerning the possibility of confounding 
spasm of the deep urethra with true organic stricture. If the precaution 
be taken to commence the urethral examination with a large-sized blunt 
steel instrument, thoroughly warmed, and to proceed as directed, error is 
hardly possible. In a doubtful case, if the meatus is very small it may 
not be possible to use a large enough blunt steel instrument to decide the 
question of spasm. A surgeon may sometimes declare that no instru- 
ment will pass because he has used a fine whalebone to commence with, 
and having caught this instrument in some follicle, has been unable to 
reach the bladder ; or he may have passed the instrument into the blad- 
der, and finding it is held somewhat by spasmodic contraction on its way 
out, has decided that there is tight organic stricture equivalent to the 
size of the instrument. Finally, if no instrument can be passed and the 
question between spasm and true stricture remains undecided, a general 
anaesthetic may be administered, when a filiform bougie in the case of 
tight stricture or a large instrument when urethral spasm exists may 
be introduced after all attempts without the anaesthetic have failed ; and 
thus a stricture, if present, may be located, its permeability ascertained, 
and its calibre estimated. 

Treatment. 

There is no one method which can be applied to the treatment of all 
strictures. 

The general treatment consists in the employment of such remedies as 
are known to have special value in inflammatory conditions of the genito- 
urinary tract, while those things which are known to be a sourse of irri- 
tation to this region should be discreetly avoided. 

The surgical treatment of stricture is of great importance. Various 
surgical measures have been employed, the principal and most important 
of which are dilatation, progressive or rapid, urethrotomy, internal and 
external, divulsion and electrolysis. 

It cannot be reasonably stated that all strictures should be treated by 
any one of the various methods in vogue. Electrolysis has been weighed 



124 VENEREAL DISEASES. 

by experience and found wanting. We have tested it thoroughly and re- 
ject it absolutely. 

It is extravagant to state that all strictures should be cut — a doctrine 
which, although never universally accepted, has been too widely applied 
of late years by those who looked upon the urethra as a canal with a uni- 
form calibre throughout, and regarded it as necessary to remove by in- 
cision any encroachment upon this calibre. It is equally unjust, on the 
other hand, to say that all strictures should be dilated, for there are de- 
cided exceptions to such a rule, and it is as impossible to generalize with 
respect to this method of treatment as it is in regard to the others. Some 
strictures are more satisfactorily treated by cutting; many others, and 
probably the majority, are well adapted to the treatment by dilatation, and 
should be treated by this method. 

The choice between dilatation and cutting should generally be made 
in favor of the former, but the size of the stricture is not necessarily a 
guide to the choice of treatment. Some very tight strictures can be 
easily dilated and are therefore appropriate for this method, whereas 
some very large strictures, while the dilating instrument can be readily 
passed, yet, on account of the elasticity and resiliency of the tissues, will 
recontract so rapidly that anything approaching a cure is impossible un- 
less cutting be resorted to. 

To summarize the various methods of treatment as applied to the dif- 
ferent forms of stricture, we might lay down the following rules : 

1. All soft strictures, whether of the anterior or posterior urethra, 
should be treated by dilatation. 

2. Strictures of a fibrous character, whether of small or large calibre, 
should be treated by dilatation at first, and when dilatation fails or the 
stricture is intractable beyond a certain point by this method, urethrotomy 
should be resorted to. 

3. Strictures of large or small calibre which are readily dilatable, 
but which recontract after a very short interval so as to render it neces- 
sary to continue the use of the dilating instrument at frequent and short 
intervals, should be cut for the purpose of making such intervals of longer 
duration. 

4. Strictures of the anterior urethra which require cutting should be 
treated by internal urethrotomy. 

5. Strictures which occur at the bulbo-membranous junction or be- 
hind it, and require cutting, should be treated by external urethrotomy. 

6. Strictures of small calibre which on account of their depth and 
proximity to the posterior urethra are accompanied by severe posterior 
urethritis and cystitis are sometimes more suitably treated by external 
urethrotomy on account of the additional benefits derived through the 
efficient drainage of the bladder and posterior urethra, which is ob- 
tained by means of this operation. 



STRICTURE OF THE URETHRA. 125 

7. Strictures of the bulbous and bulbo -membranous urethra which 
are constructed of fibrous inodular tissue should be treated by external 
urethrotomy and the mass of inodular tissue excised. 

8. Irritable strictures, and those occurring in individuals particularly 
prone to urethral chills after the employment of instruments in spite of 
proper antiseptic precautions, may be properly treated by external or 
internal urethrotomy, according to the depth of the stricture, and 
sometimes with more satisfactory results than by dilatation. 

Electrolysis. — Electrolysis is mentioned only to be condemned. Its 
claims have not been established. It is just now, however, one of the 
methods in use, and therefore should be described. 

Generally speaking, the electrolytic treatment of strictures is employed 
by two methods — one in which the strength of the current applied is of 
great, and the other in which it is of feeble intensity. The principle upon 
which rests the alleged value of the galvano-caustic chemical action lies 
in the fact that a cicatrix remaining after the application of a caustic 
alkali is soft and not retractile in character ; that when a galvano-cautery 
is applied to living animal tissue it is found that at the positive pole there 
exists such a cicatrix as is produced by the application of an acid, while 
at the negative pole is found one similar to that produced by the action 
of caustic alkalies. The method of electrolysis, as recommended by Fort, 
is an example of the employment of the galvano-caustic current of strong 
intensity, and his instrument resembles somewhat the Maisonneuve ure- 
throtome. The other method of electrolysis, which consists in the appli- 
cation of a current of feeble intensity to the strictured area, constitutes 
what is known as the Newman method. The instrument employed is a 
metal olive bougie, of a size as large as can be introduced in the urethra 
and engaged in the stricture. The galvanic current, which does not ex- 
ceed three to five milliamperes, is applied for about ten minutes, at the 
end of which time the bulbous instrument is supposed to pass with greater 
facility through the strictured area. 

It will be seen from a description of the instruments employed in these 
two methods that one is shaped like a cutting and the other like a dilat- 
ing instrument; that one is rapid and employs a current sufficient to en- 
able the blade to penetrate the tissues ; that the other is mild and gradual 
and rather aims at distending the constriction. It is therefore more than 
doubtful whether the addition of the electric current accomplishes any 
more in these two operative procedures than what is attained by instru- 
ments so closely resembling them, minus the addition of electricity, and, 
in fact, there is a well-founded belief that the electro-chemic action pro- 
duces a detrimental effect upon the tissues. 

Progressive Dilatation. — Steel instruments, nickelled, conical in shape, 
are most serviceable, and do the most accurate as well as the most effec- 
tive work in dilating the canal, either pendulous or deep, provided 



126 



VENEREAL DISEASES. 





Sj 



the size of the instrument is as large as No. 10 American (15 
Prench). Should the stricture be smaller than this size, soft instru- 
ments are best to commence with. 

The conical instrument (Fig. 67) tapers for 
two and three-quarter inches, and should be 
made upon what is called the short curve, with 
an extra shortness of the curve at the last half- 
inch near the beak, since this extra curve 
greatly facilitates introduction, especially at the 
hole in the triangular ligament, by keeping the 
point of the instrument against the roof of the 
canal. It should also taper in the direction of 
the handle after maintaining its full size for 
about two inches. With this instrument the 
meatus, which is often somewhat contracted, is 
not kept upon the stretch while the deeper por- 
tion of the canal is being distended. Such an 
instrument, as large as the stricture will admit, 
lubricated and warmed, should be passed with 
great gentleness well into the bladder. The 
power of the instrument is great, being, as it is, 
a compound of wedge and lever, and the surgeon 
should exercise sufficient control so as not to do 
damage to the urethra. The passage of one 
such instrument as this is equivalent to the 
passage of from seven to nine sounds of the 
blunt pattern, since the conicity extends through 
as many sizes. 

The instrument is to be introduced, and 
then, very gently, immediately withdrawn. If 
the urethra be irritable at the first sitting, only 
one sound should be passed — a sound of mod- 
erate size. 

The time most appropriate for a reintro- 
duction of the steel sound in case of stricture 
of large calibre must be determined by the 
effect produced by the instrument upon its 
trial trip. The immediate effect is often only 
an increase in the amount of pain experienced 
during urination. 

After a day or two the discharge from the urethra often visibly in- 
creases ; but this subsides spontaneously or by the aid of a very mild in- 
jection, and at the end of four or five days the symptoms for which the 
sound was introduced have reached the same grade as that at which they 




H 



/ 




STRICTURE OF THE URETHRA. 127 

existed at the moment of the first introduction of the sound. Forty-eight 
hours should be allowed to pass, or even longer, after the first instrument, 
and then a sound of one or two sizes larger may be introduced, but it is 
well to precede this by a smaller instrument. 

The result of this second instrumentation is that the symptoms are 
less aggravated by it than they were by the first, improvement arrives a 
little sooner, is more marked, and remains longer. In this way, increas- 
ing the sizes and using on each occasion a conical sound as large as will 
pass, the symptoms of the stricture generally yield entirely. The most 
effective treatment by large instrument is that which leaves an interval of 
one week between the passages of the sound. 

After the symptoms have disappeared the treatment should be discon- 
tinued gradually. In some mild cases of stricture, not resilient and not 
traumatic, treatment may be suspended entirely after a few weeks, and 
the patient is and remains well for an indefinite period, excepting that he 
is capable of getting a urethritis from a lighter cause than if he had never 
had previous trouble. If he does not expose himself, however, to the 
causes of urethritis, he may marry and remain well without ever showing 
any symptoms of lack of health in his urinary or genital apparatus ; but 
often at the end of a certain period, whether a new provoking cause be 
added or not, symptoms of irritation arise, indicating recontraction of 
the strictured area, when the passage of sounds is again called for, the 
single introduction of which may be sufficient to carry him over another 
period of similar or longer duration before the evidence of recontraction 
again recurs. By stringing out and extending the intervals in this man- 
ner it is often possible practically to discontinue the use of the sound. 
This is especially true concerning strictures of large calibre of the pendu- 
lous urethra, those for which such splendid results in the way of radical 
cure are claimed by the advocates of the perpetual use of the knife. 
Truly, in those cases cured by dilatation, the urethrameter, if screwed up 
to make the bulb large enough, will detect tight places along the pendu- 
lous urethra after cure ; but so it would have done when the patient was 
virgin of all disease, and it has already been shown that tight places in 
the pendulous urethra, without symptoms, need not be strictures at all. 

There is a class of strictures which produce varied symptoms — 
generally of mild urethritis — which do not yield entirely to dilatation, 
nor do their symptoms disappear under the use of the steel sound. 
They are resilient, that is, they have in them that tenacious, elastic, re- 
tractile quality which does not allow dilatation to affect them favorably 
beyond a certain point. The symptoms yield, but do not entirely disap- 
pear. A little discharge in the morning continues to mock the efforts of 
the surgeon and to disgust the patient with his disease. In these cases, 
after being certain to locate the symptoms accurately in the stricture, and 
not to be deceived by ascribing gleet due to diathetic or other cause to a 



128 VENEREAL DISEASES. 

tight spot found in the urethra, the advisability arises of internal urethro- 
tomy within the pendulous urethra if the stricture be located in that re- 
gion. Under these circumstances, the operation offers a good chance of 
success in ridding the patient both of the final remains of his symptoms 
and of the necessity for a continuation in the use of sounds — if the surgeon 
cuts wide enough at any one point and passes entirely through the un- 
yielding contractile ring of stricture. 

The treatment by internal urethrotomy, however, is generally applic- 
able only to the pendulous urethra. All organic strictures at or deeper 
than the bulbo-membranous junction should, if possible, be treated by dila- 
tation alone — by dilatation to the greatest limit to which it can be carried 
with gentleness — and this will cure the symptoms, or so nearly cure them 
that most sensible men who are made familiar with the dangers of internal 
urethrotomy in the curved portion of the urethra will be satisfied with the 
result. 

Such a cure, or relative cure of stricture in the deep urethra, espe- 
cially in bad cases of inodular stricture, cannot be maintained excepting 
at the expense of constant dilatation. The patient is condemned to pass 
an instrument, at such intervals as may be found necessary (about once a 
month, and after a time at longer intervals) , for the remainder of his life 
in order to keep down his symptoms and to prevent the recontraction of 
his stricture. And this is still the case, no matter by what treatment the 
urethra has been brought to such a size as to allow the passage of a full- 
sized instrument into the bladder. Eepeatedly does the surgeon find, in 
hospital and dispensary practice, cases of tight stricture in the curved 
urethra which have already been subjected once, twice, or perhaps three 
times to internal urethrotomy, or even to external urethrotomy. We have 
performed perineal section more than once under each of these circum- 
stances, when the patients, from neglect to pass the sound continuously 
after a former cutting, had allowed the urethra to close at the point of 
stricture. And we have treated a large number by dilatation after recon- 
traction had followed the cutting operation. 

Stricture of large calibre in the pendulous urethra may be treated so 
that its sympoms may cease forever, without the necessity for any further 
use of instruments in the canal. 

The same is true regarding the treatment of stricture of the deep 
urethra. 

Eesilient stricture of large calibre in the pendulous urethra is often in- 
curable except by the knife ; and internal urethrotomy, if the cut be large 
enough, will generally cure the symptoms of such a stricture so that they 
will not return, although no instruments are used in the urethra after the 
cut is well. 

Small organic strictures in the pendulous urethra are probably always 
best managed by internal urethrotomy. 



STRICTURE OF THE URETHRA. 129 

Strictures of the deep urethra, when organic and situated at or beyond 
the bulbo-membranous junction, cannot, all of them, with certainty be 
radically cured by any operation or by any treatment. The best treat- 
ment in these cases is dilatation when practicable. Sometimes, after 
dilatation has been maintained for a long period, the tendency to recon- 
traction ceases, and the patient remains well, so far as symptoms are con- 
cerned, without the necessity of any further instrumentation in the urethra. 
Possibly a like cure may occasionally follow internal urethrotomy; but, 
in the majority of instances of nodular, organic, and traumatic strictures 
of the deep urethra a cure is not obtained radically by any operation yet 
known, and the patient's safety consists in a maintenance of the calibre 
of his urethra by the occasional passage of a full-sized instrument through 
the obstruction for the rest of his life — a task not considered at all diffi- 
cult by those who do it. 

Strictures of small calibre in the pendulous urethra, when they are 
fibrous and resistant, should be cut, since they are quite certain in the 
long run to prove resilient, and require cutting perhaps after much time 
has been lost in attempts at dilatation. If they prove too narrow to re- 
ceive the urethrotome, their calibre may be raised in a few days by dila- 
tation, and then, as soon as the urethrotome will pass comfortably, they 
may be cut. 

Tor all strictures of the deep urethra dilatation should be the rule 
and all operative measures the exception, for the double reason already 
stated : 1. An operation may mean unnecessary danger to the patient, and 
such a risk as his physical condition may not warrant. 2. After cutting 
internally or externally, and after divulsiou, a radical cure is not attained 
in most instances — only relief as a rule, which is made effective by a con- 
tinuance of dilatation, at more or less prolonged intervals, for an indefi- 
nite period. 

Dilatation of stricture of small calibre is done much after the man- 
ner advised in the case of stricture of large calibre, with the excep- 
tion that, when soft instruments are used, the intervals may be consider- 
ably shortened. Practically, however, the rule is the same. When the 
effect of one dilatation is at its height, another larger instrument 
should be gently introduced and immediately withdrawn. With very 
fine instruments, one day is a long enough interval to be allowed to 
pass after the first sitting ; then the interval may be raised to two, 
then to three and four days, with advantage. As soon as size 10 Ameri- 
can is reached, soft instruments may be abandoned and the dilatation 
continued with conical steel sounds, as in the case of stricture of large 
calibre. 

In attempting to dilate a stricture of very small calibre considerable 
difficulty may sometimes be encountered. After a small size steel sound 
has been tried in vain, an effort to reach the bladder may be made with 



130 VENEREAL DISEASES. 

a small, soft, black conical bougie, sharp-pointed, not olivary (Fig. 68). 
Several small sizes of these may be tried. 

If any instrument so far tried passes the stricture, the amount of ease 
with which it glides through the tight spot should be estimated, the in- 
strument immediately withdrawn, and, unless there be some special rea- 
son to the contrary, the patient should be let alone to see what effect will 
follow the first instrumentation. If urethral fever follows, and especially 
if the patient has albumin in his urine, all subsequent explorations must 
be made with special care, and with the proper antiseptic precautions and 
medical aids for the prevention of chill, which will be mentioned later. 

If none of the instruments thus far tried will pass, a very valuable in- 
strument still remains — the filiform whalebone bougie, with the point 
twisted into spiral, or bent so as to be thrown out of the axis of the shaft 
of the instrument (Fig. 60, p. 120). 

A small syringeful of hot sterilized oil is first thrown into the urethra, 
and then the surgeon feels the anterior face of the stricture with the 



O.TlHMANNftCO 

Fig. 68. 

twisted end of one of these fine whalebones. By advancing the instru- 
ment during rotation, with the urethra made tense by pulling upon the 
penis, the tip of the filiform bougie is presented at different points upon 
the face of the stricture, and finally, in a skilled hand, is quite certain to 
find the orifice of the stricture and to enter it. Once entered, the rigidity 
of the whalebone comes into play, and the instrument promptly passes on 
and enters the bladder. It is rare indeed to encounter a stricture into 
which one of these slender little instruments cannot be made to pass; 
nearly all the so-called impermeable strictures yield to them. The main 
difficulty in their employment is the facility with which the point becomes 
entrapped in the mouths of dilated follicles, or of a false passage, should 
one exist. This defect may in a measure be overcome by the well-known 
device of crowding the urethra full of these fine threads of whalebone, 
and then pushing upon them alternately until the one which presents at 
the mouth of the stricture passes on into the bladder (Fig. 69). An at- 
tempt to widen the mouth of the stricture by distending the urethra in 
front with air or hydrostatic pressure is an expedient sometimes tried in 
order to gain an opening wedge, to be the starting-point of further 
dilatation. 

But when, in the case of a very tight stricture, a fine whalebone has 
been introduced only after long patient trial, and especially if there be 
actual or impending retention, the surgeon's course should depend in a 
measure upon the character of the stricture, as well as the patient. 



STRICTURE OF THE URETHRA. 



131 



If the stricture be modular, complicated with perineal fistula ; or very- 
hard and of traumatic origin; or attended by perineal abscess; or 
(above all) by infiltration of urine; or if the patient be hard to man- 
age, having been partly cured before and then allowed himself to re- 
lapse; or if he be urgently pressed for time, or subject to repeated and 
prostrating attacks of urethral fever (his kidneys being presumably 
sound) — under any of these circumstances perineal section upon a guide 
is called for, and should be performed at once or within twenty-four 




Fig. 69.— Method of Finding the Opening of a Tight Stricture with Filiform Bougies. 



hours. The filiform guide may be tied in the urethra and left there 
until the operation, if there has been great difficulty in procuring an 
entrance. 

If the case be not urgent on any of the above grounds, while it has 
been quite difficult to pass the stricture with the filiform bougie, the mild 
and very efficient expedient of continuous dilatation may be used. 

Continuous dilatation is the action exerted upon a stricture by the con- 
stant presence of an instrument passed through it. The whalebone or 
small gum elastic bougie, once inserted, is simply to be retained in place 
by a piece of heavy silk tied tightly around it near the meatus. The two 
ends of the silk are then tied together so that the knot shall lie upon the 
frenum just at the curve of the corona glandis, and then the separate ends 
are carried around on either side under the corona, and tied with moder- 



132 



VENEREAL DISEASES. 



ate tightness upon the dorsum. The distal end of the bougie should 
reach the neck of the bladder, or rest just beyond it (Fig. 70). 

In this condition the patient is sent home and told to keep quietly 
about the house. In twenty-four hours the whalebone may be removed 
and one several sizes larger introduced with ease. This is in its turn 




Fig. 70. 



tied in. The patient urinates easily alongside of the instrument ; some- 
times there is incontinence. The continuous pressure causes, first, mus- 
cular action, spasm, and the bougie is grasped, then relaxation of spasm, 
then inflammatory swelling, then absorption, and usually suppuration. 
The second instrument may be left in two days or more. In this way, in 



STRICTURE OF THE URETHRA. 



133 



a week most strictures (if commenced with very small) may be raised a 
number of sizes. In replacing a new bougie, generally an increase of two 
or three sizes is possible, but it should glide in easily without pressure. 
It is well during the retention of the bougie to keep the anterior canal 





^itiiUMJMllMd.uUJuJ,j^^ , , 





Fig. 71.— Kollman Urethral Dilators. 



flushed out with an antiseptic solution (boric acid three per cent, or per- 
manganate of potassium 1 : 4, 000) . The larger the calibre of the stric- 
ture, the less promptly, as a rule, does continuous dilatation affect it. 
After the stricture has reached a reasonable size, treatment by ordinary 
dilatation may be commenced ; but the intervals must be rather short at 



134 VENEREAL DISEASES. 

first, since a stricture promptly raised to a large size by this method very 
promptly falls back again if let alone. 

There are some cases of tight stricture in which one may be content 
with simply passing a filiform instrument and not tying it in, trusting 
that on the following day a larger size may enter, as in ordinary treat- 
ment by dilatation. 

Finally, there are cases not quite desperate enough to justify external 
urethrotomy, not able to give the time to ordinary dilatation (although it 
does not call for a day in the house, much less in bed), and yet urgent 
enough to justify prompt measures which shall afford speedy relief. For 
this class of cases two operations remain — internal urethrotomy or divul- 
sion (see p. 142) . 

Rapid Dilatation. — This method differs from the previous ones in that 
it aims at re-establishing the normal calibre of the canal at one sitting. 
In other words, instead of being progressive, gradual, and slow, it uses 
force. A number of instruments fashioned on the same principle have 
been invented for the application of this method, notably by Tuttle, Ober- 
lander, and Kollman (Fig. 71). These instruments are capable of ex- 
erting a great deal of force, and permit the distention of the canal very 
much beyond its normal calibre, as high as 45 on the French scale. This 
method, which is somewhat rough and exercises its extreme distention on 
a large portion of the urethra not included in the stricture, is something 
of a compromise measure between the mild and slower means of progres- 
sive dilatation and the rapid immediate means of " divulsion " (to be re- 
ferred to later), and has nothing in its favor to place it before either of 
these two procedures in the choice of treatment. 

Internal Urethrotomy. — Stricture far forward in the urethra or con- 
tracted meatus should be cut. This is most conveniently done with a 
straight, blunt bistoury. The prepuce should be retracted, the head of 
the penis seized between the thumb and index finger of the left hand, and 
the blade of the knife introduced to the proper depth in the urethra. It 
is generally best — often necessary on account of the pocket — to cut the 
meatus along the floor of the urethra ; but in some peculiar shapes of the 
glans penis it may be better to cut the roof of the urethra. This opera- 
tion may be rendered absolutely painless by the employment of cocaine or 
eucaine. 

A convenient method of procedure is to have on hand a half -grain tablet 
triturate of either of these drugs, which is to be placed just inside the 
meatus ; it becomes softened by the normal moisture of the canal, and is 
left in contact long enough for absorption to occur. 

When all is ready the surgeon squeezes the glans penis with the 
thumb and finger which hold it, and at the same moment slowly and 
steadily draws the sharp blade along the floor of the urethra, appreciating 
with his surgical sense of touch the resistance offered to the knife by the 



STRICTURE OF THE URETHRA. 



135 




encircliug band of stricture. When this yields and is thoroughly cnt 
through, he can appreciate it at once by a cessation of the feeling of re- 
sistance which the band has given, and he has cut enough. If it is only 
a pouched meatus which the surgeon has to transform into a slit, he regu- 
lates his incision accordingly. Civiale's or any 
other meatotome may be used, if the surgeon pre- 
fers. The operator may place the index finger of 
his left hand along the integument beneath the 
urethra, so that the stricture band may be felt be- 
tween the finger and the knife. In this position he 
cuts directly upon the finger until he can feel the 
point of the knife against the soft tissues and ap- 
preciate the absence of the band between the finger 
and the knife. The band of constriction behind a 
tight meatus is readily detected with a bulbous in- 
strument j hence the bulbous urethrotome (IFig. 72), 
a modification of Civiale's, is useful in incising it 
at the point of resistance. The meatus is often cut 
improperly. The fault lies in either cutting too 
much or too little. Many cases are seen in which 
an unsightly and unnecessary deformity is produced 
by the operation of meatotomy, amounting in some 
instances almost to a balanic hypospadias, the re- 
sult of which is to scatter the urinary stream as it 
passes the meatus, thereby causing much annoyance. 
On the other hand, the meatus is insufficiently cut 
when the external fissure only is enlarged. Such a 
case has the outward appearance of an ample -sized 
meatus, but by an attempt to introduce a bulbous 
bougie it is discovered to be surprisingly small. The 
interior constrictmg band has been left untouched, 
and should be cut with a bistoury or bulbous ure- 
throtome, always upon the floor. 

The cut meatus sometimes bleeds profusely, 
sometimes hardly at all. The expedients for stop- 
ping the blood consist in applying pressure for a 
time, by the application of a strip of rubber plaster 
around the extremity of the penis, or by a snugly ap- 
plied narrow finger bandage, with or without the urethrotome; amodiflca- 
addition of a small flat splint. In cases of moderate «oa of civiaie's. 
bleeding the application of several coats of collodion to the well-dried 
meatus, while it is held under pressure to prevent the oozing until the 
collodion has set, may answer the purpose. There is no danger from ex- 
cess of bleeding, for the patient can stop the hemorrhage until the surgeon 







136 VENEREAL DISEASES. 

arrives by digital compression, and the surgeon can always finally arrest 
it by properly applied pressure, as described above. 

It is better not to put subsulphate of iron into the urethra, since this 
substance is likely to leave the walls of the canal inflamed, hardened, 
and ready to suppurate. Much time in the treatment may be lost on ac- 
count of the use of this haemostatic. 

When there is little or no bleeding, some cotton or lint, so arranged 
as to be retained beneath the prepuce, is all that is required. Often 
when cocaine is used no bleeding occurs at the time, on account of its con- 
tracting effect upon the small vessels ; and soon after this effect has worn 
off the bleeding becomes quite free. 

It is always wise to caution the patient to apply a snug bandage be- 
fore retiring for the first one or two nights, as when erection occurs dur- 
ing sleep it may bring on free hemorrhage from the freshly cut surfaces 
of the wound. 

A cut orifice will heal up immediately if left to itself. This is pre- 
vented by having the patient return in two, four, eight, and twelve days 




Fig. 73.— Straight Conical Steel Sound (Short). 

to allow the surgeon to pass a straight steel instrument (Fig. 73) through 
the meatus, to keep the wound open until its surfaces are covered with 
epithelium. 

The meatus sometimes bleeds more freely when the instrument is 
passed for the first time than when it was cut, and should be controlled 
in the same manner. Another plan to prevent closure of the wound is to 
furnish the patient with a hairpin, with the curved portion rebent and 
the angle much increased in size, so as to be large enough when oiled, 
and passed down the urethra, to lie with one leg of the pin against the 
roof of the urethra, the other leg at the bottom of the whole length of the 
wound, while the two points are outside. The patient is told to pass this 
on the night after being cut, and on the following two nights j then to 
skip a night for two passages of the hairpin ; then to skip two nights for 
three passages. By the end of this time (a full fortnight) the meatus 
has often healed entirely, or so nearly that it may be left to itself, and, 
if thoroughly cut and healed open, it never recontracts. 

When internal urethrotomy has become necessary in the treatment of 
a stricture of the pendulous urethra more distant from the meatus, one 
of the various special instruments devised for this operation is used. 

The urethra is previously washed out with a mild boric-acid or saline 
solution, and about two drachms of a four-per-cent solution of cocaine or 
eucaine are inject-ed and retained about ten minutes. 



STRICTURE OF THE URETHRA. 



137 



The urethrotome of Civiale represents a type from which several modi- 
fications have been constructed (Fig. 72) ; the principle of this instru- 
ment is shown in the accompanying figure (Fig. 74). The bulbous 



Fig. 74.— Civiale's Uretlrrotome. 

extremity is passed beyond the grasp of the stricture, and the concealed 
blade is unsheathed while the instrument is withdrawn so as to cut the 
stricture from behind forward. This instrument or any of its modifica- 
tions are applicable to strictures of a calibre not smaller 
than 16 or 17 Trench, and when it is desired to incise 
bands or contracted areas to a limited extent, and pro- 
ceed thereafter with dilatation. 

It must be stated that cutting a stricture with any 
instrument does not produce a radical cure, nor allow 
the patient necessarily to dispense with a continual 
use of the sound, although such a result may be ob- 
tained and it should always render it possible to ex- 
tend greatly the intervals between the passages of the 
sounds. 

Otis' dilating urethrotome is simple and strong. 
It is a modification of a number of previous types, 
so combined as to form an instrument which performs 
its functions very accurately. It consists (Fig. 75) of 
a shaft, the blades of which may be separated by a 
screw movement in the handle, and a small knife, 
which fits in a groove of one of the arms of the dilat- 
ing portion and which, concealed near the distal end, is 
exposed and brought into action when its handle at 
the proximal end of the instrument is drawn out. A 
dial plate in the handle registers the degree of separa- 
tion of the blades. 

la using this instrument, the location and extent 
of the stricture to be cut are at first definitely decided 
upon, with the urethrameter or bulbous sound. Then 
the urethrotome is introduced (dial plate and knife 
toward the roof of the urethra) so deeply that the point 
at which the knife blade shall emerge shall be at 
least three-quarters of an inch deeper in the ure- 
thra than the deepest limit of the stricture. This 
is necessary in all strictures of large calibre; with- 
out it the deepest parts of the stricture — those most distant from the 
meatus — are not cut. For the lower blade of the instrument, in open- 





FiG. 75.— Otis' Dilating 
Urethrotome. 



138 VENEREAL. DISEASES. 

ing, pushes away the urethra, making it slide back from the upper 
blade; so that, no matter how accurately the meatus may be held 
against the shaft of the urethrotome, the position of the knife relatively 
to the stricture slides forward proportionately to the amount of separa- 
tion of the blades, and therefore, when the knife is brought into ac- 
tion, it may commence the cut entirely in front of the deepest (often the 
tightest) portion of the stricture, unless special care is taken to avoid this 
mistake. 

When the instrument has been properly placed, the blades are separ- 
ated until they mark the size to which it is desired to cut the stricture. 
In cutting, the handle of the knife is withdrawn far enough to make the 
cut in all at least half an inch longer than it was originally decided that 
the stricture measured. Now the blades are to be rapidly approximated, 
and the knife is returned to its concealment before withdrawing the in- 
strument. If several points of constriction exist in the course of a single 
strictured area, they may all be included in a single incision along the 
roof. If multiple stricture exists and a considerable interval of healthy 
urethra separates them, they may be cut at the same sitting, but by differ- 
ent operations, the deeper one being cut first. The flow of blood forms 
no material impediment to cutting the second stricture. If the meatus 
is to be cut, it should be cut along the floor as the first step in the opera- 
tion, if this has not already been attended to in the preliminary examina- 
tion. No ether is necessary in the performance of this operation. Co- 
caine or eucaine may be used, the danger of cocaine being always borne 
in mind. It should be done slowly, for accuracy and precision are essen- 
tial factors of success. 

After the cutting has been accomplished, it is well to pass a bulbous 
or straight steel sound over the cut region, to decide whether the cutting 
has been efficient and has thoroughly relieved the constriction. 

If this is found not to be the case, the urethrotome should not be rein- 
troduced. The second cut is likely to pass through the stricture at a differ- 
ent point, and a third cut to take still another route. Thus the stricture 
becomes partly cut in a number of places, its outermost circle not being cut 
through anywhere; and more cutting is done than is justified by the end 
in view, since each cut increases the possibility of cicatricial changes. 
The way to avoid the necessity for a second cut is to make the first one 
deliberately, to locate it accurately, and to make it deep enough. If this 
is not done, it is wiser not to perform a second operation until it is deter- 
mined that dilatation will not accomplish the desired result, and not until 
it has been practised for a sufficient period after the first cut has healed, 
and then to start afresh, as if nothing had been done previously. 

It remains to determine how deeply to cut a given stricture of large 
calibre in the pendulous urethra. This cannot be absolutely decided by 
any criterion. Dr. Otis, as already stated, has fortified his followers with 



STRICTURE OF THE URETHRA. 139 

a scale, based upon an alleged constancy of relation between the normal 
size of the urethra and that of the penis in repose; yet this scale (which 
is certainly only approximate) does not give its followers the satisfaction 
of doing the whole operation at a single cut. In many operations the 
urethrotome is introduced twice or more often at the same sitting; and 
very frequently it is found, after some days or weeks, that the stricture 
has to be cut over again. When this method was first taught it was not 
uncommon to see cases in which there had been repetitions in the cutting, 
to the extent of four times at different sittings, and in the same individual, 
and that too without resulting in a cure. Consequently it is rather idle 
to attempt accuracy by measuring so uncertain an organ as the penis, even 
if the scale possessed the accuracy which its inventor ascribes to it ; and 
the question remains: What rule, if any, have we to go by? 

In answer, it may be stated as a general proposition that the strictured 
point which will not yield to dilatation must be cut so as to be somewhat 
larger than the normal urethra at that point ; and that, to insure the best 
results, a single cut should be made — a cut, if possible, to pass beyond all 
diseased tissues and into the healthy tissue. 

This result is probably often attained by following the measurements 
of Dr. Otis, since his estimation of the size of the urethra is extreme ; but 
even his measurements will not suffice in some cases in which inodular 
tissue has involved the whole substance of the corpus spongiosum, while 
often they are unnecessarily high. 

A fair rule to go by is first to establish the fullest size to which the 
normal meatus may be distended — the normal meatus not strictured and 
without pockets — and to cut the stricture, after having screwed up the 
urethrotome to mark not less than two sizes (American, three or four 
sizes ^ rench) higher than that limit. Should the meatus be strictured 
congenitally or by disease, the surgeon's judgment must guide him in the 
extent of his incision, both of the meatus and of the deeper-seated stric- 
ture, remembering that the normal meatus of the full average-sized 
penis in the American will range very close upon 20 American scale (30 
French). In other words, a conical steel instrument of size 20 will pass, 
by its own weight, the normal meatus (without pockets) in the average 
American male taken at random, with fair-sized genitals, or certainly 
may be passed with a little coaxing, putting the meatus more or less on 
the stretch, without in the least tearing or injuring it. A penis of less 
size will have a more moderate urethra, as a rule. 

It has been found by experience, as Dr. Otis has shown, that the 
breadth of the knife blade does not count, and that if the blades of the 
urethrotome be separated to 20 and the cut then made, the strictured 
point will be found to be cut not above size 20. Therefore, the limits of 
cutting which are given are quite moderate, for the meatus is normally the 
smallest part of the canal, and an incision at least two sizes larger, lower 



140 



VENEREAL. DISEASES. 




down, is not extravagant, since the cut is quite certain to lose one size 
while healing. 

If, after healing, it is found that the symptoms persist, and the 
resiliency of the stricture remaining shows that the outside fibres have 

not been cut through, then another 
operation may be performed, the 
surgeon being fortified by the 
knowledge gained during the first 
operation, and the cut on the sec- 
ond occasion may be made two or 
even three (American) sizes larger 
than before; but dilatation with 
increasing intervals should always 
be tried before recourse is had to a 
second cutting. 

When the calibre of a stricture 
in the pendulous urethra is too 
small to admit the Otis urethro- 
tome, an effort should be made to 
dilate the narrow point sufficiently 
to receive the instrument. This 
may be done either by the aid of a 
whalebone guide and tunnelled 
sound or by a preliminary partial 
urethrotomy performed with a 
slender instrument constructed on 
the Maisonneuve principle, to cut 
from before backward. The Mai- 
sonneuve instrument consists of a 
cui;ved conductor, upon which is 
screwed a fine flexible bougie as a 
guide. A small triangular blade on 
a wire staff slides in the groove of 
the conductor and cuts the stricture 
from before backward. The apex of 
the blade is protected by a blunt 
shield so that the healthy part of 
the canal is distended, as the knife 
is thrust along the curve toward the stricture, while the latter is cut by the 
free edge of the knife. This instrument, which is curved, is adapted for 
internal urethrotomy beyond the bulbous portion of the urethra. A better 
instrument for the pendulous urethra is a modification of the Maisonneuve, 
known as Fluhrer's (Fig. 77). This consists of a grooved conductor, 
nine and a half inches long, 12 French calibre, slightly curved at its distal 








Fig. 76.— Maisonneuve 
Urethrotome. 



Fig. 77.— Fluhrer's 
Urethrotome. 



STRICTURE OF THE URETHRA. 141 

end. A triangular blade on the end of a stylet, similar to that of the 
Maisonneuve instrument, slides through the groove of the conductor, 
being protected at its apex by a small blunt shield. This instrument will 
incise the urethra up to 18 to 24 French. All strictures of the anterior 
canal except when in close proximity to the meatus should be cut upon 
the roof, and therefore the grooved surface which conducts the. cutting 
blade of any of the instruments described should be turned toward the 
roof of the urethra when the stricture is in the pendulous urethra. 

Internal urethrotomy beyond the pendulous urethra is an operation 
which has its adherents, but for several reasons its adoption is not advised. 
In the first place, the bleeding is likely to be troublesome and much harder 
to arrest than hemorrhage from the pendulous urethra. There is certainly 
much greater danger of septic infection when the urethra is incised be- 
yond the cut-off muscle. In fact, many deaths due to this operation have 
been recorded, and undoubtedly many have occurred which have never 
been heard from. Furthermore, experience goes to show that when a 
urethra is incised in the deeper region by means of external urethrotomy, 
and proper drainage is afforded through the external wound, such serious 
complications as have frequently been known to follow the operation of 
deep internal urethrotomy are seldom observed. The additional advan- 
tages afforded by external urethrotomy in permitting a close inspection of 
the strictured portion, the opportunity to incise it upon the floor as well 
as upon the roof, without going too far beyond the limits of the stricture, 
and of permitting the complete excision of inodular tissue where it exists, 
not to mention the benefits derived by the bladder and posterior urethra 
from the free drainage this operation affords, are all of obvious im- 
portance. 

The bleeding after internal urethrotomy is very variable. A deep 
incision in one patient may be attended by a moderate flow of blood, while 
a slight cut in another will bring on profuse hemorrhage. In a given 
patient, however, the amount of hemorrhage is proportionate to the num- 
ber and depth of the cuts. Generally, pressure will arrest the bleeding. 
It is best applied with the fingers placed directly over the urethra. The 
blood should be allowed to clot, and the clot that forms and protrudes 
from the meatus should be left in place and not be removed with the 
fingers, for this allows only a continuance of the hemorrhage and necessi- 
tates the formation of another clot. If the flow of blood persists, con- 
tinuous pressure from without may be tried by applying a tight bandage 
around the penis, or by binding two small rectangular splints, one along 
the urethra and the other along the dorsum, by means of a strip of adhe- 
sive plaster and then a narrow bandage. This dressing may be removed 
prior to urination and reapplied directly afterward until no further bleed- 
ing occurs. In some cases little or no blood escapes at the moment of 
operation, but later, at the time of the next urination or during erection at 



142 VENEREAL DISEASES. 

night, hemorrhage occurs which may become quite profuse. The same 
means will suffice to arrest it as described above. 

The after-treatment consists in the use of the conical steel sound at 
appropriate intervals. Until the cut surfaces of the urethra shall have 
healed over, or before the expiration of about two weeks, the posterior 
canal should not be entered by the sound. A long straight steel sound 
is well adapted for use during this period (Fig. 78). Forty-eight hours 
after the cutting, a full-sized sound — large enough to put the meatus fully 




Fig. 78.— straight Conical Steel Sound (Long) . 

upon the stretch — may be gently introduced. This is followed by hemor- 
rhage, sometimes more profuse than that which occurred at the moment of 
the operation ; but it yields more promptly, as a rule, and generally becomes 
arrested spontaneously after a few moments. It is well, however, to exer- 
cise the precaution of tying the penis up at night-time in a snug bandage, 
to prevent hemorrhage during sleep on account of erection. After another 
interval of forty-eight hours, the same full-sized sound may be introduced; 
or, if the urethra be generally inflamed so that the large size causes much 
pain, one size lower may be employed. Again, in seventy-two hours the 
process is repeated. The next interval may be four days, and the next six. 
After this one or two passages of the sound, at intervals of one week, 
often terminate the case, although in many instances a much longer time 
is necessary, and sometimes one, two, or even more sizes in the sound are 
temporarily lost, owing to inflammatory conditions in the urethra excited 
by the mechanical violence to which it has been subjected; but this may 
be regained by progressive dilatation at longer intervals when the irrita- 
tion has subsided. The cut is known to be healed when a full-sized in- 
strument can be passed without being followed by any blood ; but even 
after this it is wise to keep up the use of a full-sized sound, at longer inter- 
vals, for some time. 

If now the symptoms have disappeared, the sound may be laid aside, 
and the patient is and remains well, although manipulation with the 
urethrameter may still detect that the point cut is smaller than other 
parts of the urethra. If the symptoms recur and the stricture recontracts, 
dilatation should be practised and account taken whether or not the symp- 
toms yield, in which case recontraction may be forestalled by noting the 
interval after which the symptoms reappeared, and directing that the 
instrument be used again at about the same interval, or when there exists 
any tendency to recurring symptoms. 

It should be borne in mind that sometimes the symptoms which persist 
after a stricture has been cut and the attendant irritation has had time to 



STRICTURE OF THE URETHRA. 143 

subside may be due to inflammation deeper in the canal — posterior-ure- 
thritis — which necessarily is not relieved by the cutting of the stricture 
and will require appropriate treatment later on. The patient should be 
apprised of this fact so that he may be saved a keen disappointment in 
case he has counted upon an absolute cessation of all symptoms, notably 
the discharge. 

The complications attending this operation besides hemorrhage, which 
can always be arrested in the pendulous urethra, are those inherent to 
most operations upon the canal, and due often as much to the after-treat- 
ment by instruments as to the cutting operation. They are urethral 
fever, epididymitis, cystitis, possibly prostatic or peri-urethral abscess, 
occasionally acute uraemia, and pyelo-nephritis. None of these complica- 
tions is likely to occur when strict cleanliness has been observed, and 
when the posterior urethra has not been invaded until the cut in the an- 
terior portion is healed. Another complication, not very uncommon 
when the cut has been deep, is the formation of new inodular tissue in 
the corpus spongiosum, causing painful erection and chordee. Painful 
erections often persist for a long period and curvature of the penis may 
remain, but not as a rule unless the cut has been too deep. 

All these complications call for treatment when they arise, and many 
of them demand a cessation in the employment of instruments. Thus, the 
cut is allowed partially to close, but by dilatation later on sufficient dis- 
tention may of ten be obtained, and a second cutting operation is not neces- 
sarily required. The proper means to adopt to avoid complications aiter 
urethrotomy is to keep the patient quiet upon his back for several days 
after he has been cut, giving him plenty of bland diluents to drink and 
enough bromide or anodyne, if need be, to keep down erections. Laxa- 
tives may be required while the patient is in bed. Alkalines and oil 
of sandal wood, as administered in simple urethritis, may be of service, 
and sometimes a mild antiseptic or astringent injection, to keep the 
canal clean and remove the discharge, may be given if needed several 
days after the operation, after the patient has been permitted to be 
about again. 

Divulsion. — This operation is not at the present day held in favor by 
most surgeons to such an extent as internal urethrotomy, and the authors 
have practically discarded it, because it is rough and unsurgical. It has 
the advantage over internal urethrotomy, however, of calling for less 
after-treatment by instruments in the urethra, the hemorrhage is much 
lighter, and the effect often lasting. The danger is certainly no greater 
in this operation than in internal urethrotomy of the deep urethra. Bige- 
low's instrument is recommended in soft and yielding strictures. It con- 
sists of a shaft with an expanded extremity conical in shape, grooved on 
one side to fit over a slender metallic guide, attached to a flexible bougie. 
When the latter is in place, the divulsor is wedged by force through the 



144 VENEREAL DISEASES. 

stricture, and prevented from going too far by a shield on the end of the 
guide. 

Thompson's tunnelled divulsor, capable of being screwed up to size 
21 American scale, is used in tight strictures of the curved urethra. Fig. 
79, a, represents the instrument. By turning the handle the blades 
may be separated, h, the amount of separation being registered upon an 
index in the handle. The instrument is to be used as follows : 

The depth of the front face of the stricture from the meatus is at first 
accurately ascertained. Then a filiform whalebone bougie, twenty inches 




FIG. 79. 

long, must be passed through the stricture until its distal extremity reaches 
the meatus, the other end lying coiled up in the bladder beyond the stric- 
ture. The urethra having been thoroughly washed with warm boric-acid 
solution and anaesthetized with a four-per-cent solution of cocaine or eu- 
caine, retained five to ten minutes, the divulsor is well lubricated, the 
tunnel is threaded over th^whalebone guide, and, while the tip of the 
guide and the end of the penis are held tense with one hand, with the 
other the divulsor is slowly to be pushed along over the guide through 
the stricture and into the bladder until its point of greatest dilatability 
lies at the centre of the stricture. The outside of the divulsor is marked 
in inches to facilitate this step in the operation. 

It is necessary to take every precaution, in guiding the divulsor into 
the bladder, not to let it double up the guide in front of itself. To 
guard against this, during the whole time that the point of the divulsor 
is travelling the curved part of the urethra the guide should be pulled upon 
very gently, so that, as the divulsor slips in, the guide is being steadily 
pulled out. If too much of the guide is used in this way at any time, the 
divulsor being left in place, the guide may be again pushed forward 
through the stricture and the tunnel until all its excess is again coiled up 
in the bladder, and then, by coaxing and gentle manipulation of the divul- 
sor while the guide is being again withdrawn, the steel instrument is 
carried safely into the bladder, guided by the whalebone. 

When the divulsor is in place, the guide should be entirely withdrawn 
and the process of divulsion immediately commenced. The handle of the 
divulsor may be turned slowly or rapidly until such a grade of dilatation has 
been reached as shall have been previously determined upon, or until blood 



STRICTURE OF THE URETHRA. 145 

begins to flow rather freely from the meatus, indicating that the morbid 
tissue has been divulsed — torn through. The stricture tissue is brittle, 
and although tough it tears more easily than the sound tissue, the elas- 
ticity of which allows it to escape any considerable injury. Thus, the 
process of divulsion effects about the same result as internal urethrotomy, 
with the difference that the torn tissue bleeds less than a similar wound 
made with the knife would, and has very little tendency to heal up imme- 
diately j both of which results are very desirable, since they do away 
with the necessity for a considerable amount of after-treatment which 
might otherwise be required. 

As the divulsor is being unscrewed preparatory to its removal, its 
handle should be gradually depressed between the thighs, and its point 
pushed forward into the bladder until the blades meet, when they may be 
safely withdrawn. Without the exercise of this precaution, it sometimes 
happens that the closing blades catch a portion of mucous membrane — 
either the ragged, torn edge of the stricture, or a fold of membrane 
lower down the urethra, and pinch it so tightly that the instrument 
cannot be disengaged by again screwing it up. The little piece of mu- 
cous membrane in such a case must, of necessity, be torn away before the 
instrument can be extricated. 

After the divulsor has been withdrawn the bleeding invariably stops 
promptly, and no other instrument should be passed into the urethra. 
The patient is simply put to bed and told to remain there from twenty - 
four to thirty-six hours, after which he may get up and go about his 
business. If he has a chill, he must be kept longer in bed, and his tem- 
perature watched to see whether the chill signifies anything more than 
ordinary urethral fever. 

The question of urethral fever, and its treatment after operations 
upon the urethra, will be discussed presently. 

After divulsion no instrument should be passed into the urethra until 
the lapse of from five to eight days. The torn tissues do not tend to unite 
as a cut does, otherwise the after-treatment is about the same as after 
internal urethrotomy. 

The possible complications following divulsion are the same as those 
liable to be encountered after urethrotomy. Hemorrhage, however, does 
not occur to any extent. 

External Perineal Urethrotomy, — This operation is imperatively called 
for by tight organic stricture deeply situated in the urethra, under certain 
circumstances, such as infiltration of urine, perineal abscess, numerous 
fistulse, and when the stricture is impermeable to an instrument passed 
from the meatus. 

The latter contingency alone does not necessarily demand external 
urethrotomy. It is also possible in such a case to aspirate the bladder 
with a fine, perforated needle above the symphysis pubis, once or twice 
10 



146 VENEREAL DISEASES. 

if need be, and then to try the urethra again with a whalebone guide. 
Some traumatic strictures also of the deep urethra are excessively tough 
and resilient, so that they will not yield to attempts at dilatation. These 
must be cut, and a much more satisfactory result may be obtained and a 
much safer procedure adopted by resorting to an external thau to an inter- 
nal section. Such a complication of stricture as stone in the bladder 
naturally calls for perineal section, since two maladies may thus be over- 
come by a single operation. 

Perineal Section with a Guide. — This operation is a simple one, much 
more so than the operation without a guide. Therefore no effort should 
be spared that may be necessary to effect the passage of a tight stricture 
with a filiform bougie and a guide introduced, whereby the operation is 

much facilitated and shortened. 

« 

If the stricture cannot be penetrated and a guide introduced before 
etherization, success may be attained when the parts are relaxed and the 
patient is unconscious. The preparation of the patient is the same as for 
any operation in this vicinity. The parts should be thoroughly cleansed 
and shaved, the bowels emptied by a laxative, and the rectum washed out 
with saline enemata. 

The guide having been passed, the patient is bound in the lithotomy 
position. The instruments required besides the common accompaniments 
of all operations, including artery forceps, scalpels, etc., are a straight 
narrow bistoury, a probe-pointed narrow bistoury or Blizzard knife (Mg. 
80), different sizes of tunnelled sounds or catheters (Figs. 81, 82), fili- 
form bougies, probed grooved director, female catheter, and perineal 
drainage tube (Fig- 83). 

In strictures of large calibre, when the operation is to be performed 
for drainage or whenever the stricture will admit the passage of a staff 
or grooved sound of any size, by using the largest size possible the opera- 

WtiWWWi 
Fig. 80.— Probe-Pointed Bistoury or Blizzard Knife. 

tion is rendered so much the more easy. If a filiform bougie has been used 
to introduce the tunnelled guide, it should be removed provided the latter 
has passed through the stricture and reached the bladder, which is demon- 
strated positively, when a tunnelled catheter (Fig. 82) is used, by with- 
drawing the stylet and obtaining a flow of urine. If this be successfully 
accomplished the bladder should be emptied and washed with a three- 
per-cent boric or boro-salicylic solution, a few ounces of which is allowed 
to remain in the bladder. 

While the staff is pressed toward the perineum by an assistant, who 




STRICTURE OF THE URETHRA. 



147 



also holds up the scrotum, an incision about two inches long is made in 
the median raphe, ending one inch in front of the anus and extending 
through the skin and fascia. The index finger is introduced into the 
wound to locate the groove on the staff ; a sharp-pointed bistoury is then 
used to incise the tissues overlying the in- 
strument, and by making a clean slit in the 
urethra its point will enter the groove. The 
probe-pointed bistoury is now substituted for 
the sharp-pointed instrument, but the latter 
should not be removed until the former finds 
the opening in the urethra and the groove on 
the guide. The probe-pointed bistoury is 
now pushed along with the staff toward the 
apex of the prostate and then withdrawn. A 
small female catheter is passed through the 
wound to the staff, which is then withdrawn 
and the catheter" thrust toward the bladder 
until fluid is obtained to denote that the 
right path has-been taken. A small grooved 
director replaces the catheter upon which the 
urethra may be further incised upon the floor 
and upon the roof, according to the nature 
and extent of the stricture. If there also 
exists stricture of the pendulous urethra it 
should be cut with the urethrotome. The 
operation is then completed by the intro- 
duction of a perineal drainage tube (Fig. 
83). 

In those cases in which the obstruction is 
too tight or too tortuous to permit the passage 
of a tunnelled catheter or staff through the 
stricture, the operator passes the tunnel of 
the catheter or sound over a whalebone bou- 
gie, which has been previously introduced as 
a guide through the obstruction, and carries 
it down to the face of the stricture. He 
then, with the scrotum and testicles drawn 
well up out of the way, entrusts the in- 
strument to his assistant, and proceeds to cut down methodically in the 
middle line layer after layer, aiming for the tip of the sound, which of 
course represents the anterior face of the stricture. As soon as the tip 
of the sound has been exposed, a curved needle, threaded with silk, is 
deeply inserted on either side through the skin and deep tissues, and 
brought out through the urethral mucous membrane, just in front of the 




148 VENEREAL DISEASES. 

anterior face of the stricture, near the tip of the sound. The needle 
being removed, each ligature is knotted to itself, so as to form a loop on 
either side. The loops are entrusted to two assistants. They form the 
best possible means of keeping the wound open without the use of fingers 




G.TIEMAJV/\/ &C0. 

Fig. 82.— Tunnelled Catheter on Filiform Guide. 

or instruments, which obstruct the light and allow the whole bottom of 
the deep wound to be freely inspected, showing the end of the filiform 
guide disappearing through the stricture among the tissues which have 
stopped the tip of the tunnelled instrument. 

It now requires a little delicate dissection in the middle line, following 
the black filiform guide, and the obstruction is cut on the end of the steel 
instrument. Care is necessary not to cut off the slender whalebone in the 
wound. The tunnelled catheter may now be easily slid forward into the 
bladder, and the removal of its stylet allowing the urine to flow freely 
through it demonstrates the success of the operation. 

The catheter should now be withdrawn and the site of the stricture 
examined. If this has involved the roof as well as the floor of the ure- 
thra, a bridge across the roof, generally with a slight pocket above and 
in front, will be noticed. This should be thoroughly cut through, or it 
may prove an obstacle to the introduction of sounds while the wound is 
healing. 

Bleeding points next require attention, and finally the bladder should 
be thoroughly examined for stone, and the finger should assure the 
operator that all the hard, cicatricial tissue constituting the stricture has 
been thoroughly cut through at each end x)f the wound. Inodular tissue 




Fig. 83.— Perineal Drainage Tube. 

should be dissected away and excised. The divided ends of the urethra 
may be then brought together by sutures, or when a large area has been 
removed the transplantation of mucous membrane may be attempted. 
This operative measure has been conducted with success by a few sur- 
geons.' The pendulous urethra should also be examined for stricture, 
which should be cut if found, which will enable the surgeon to convince 

* Keyes : Jour. Cut. and Gen.-Urin. Diseases, 1891. 



STRICTURE OF THE URETHRA. 149 

himself that he can easily pass a full-sized conical steel sound into the 
bladder through the meatus. 

A perineal drainage tube is introduced so that the eye of the instru- 
ment is just within the bladder, and through it the bladder is irrigated 
thoroughly with hot boric-acid solution ; or in the case of marked cystitis 
a solution of silver nitrate, 1 : 4,000. The tube is held in place by 
tapes tied to the waistband. 

The amount of bleeding is not generally considerable unless the bulb 
has been slit during the operation, when it is controlled by packing with 
absorbent gauze beneath the skin in front of the tube. A small packing 
may also be placed around the tube if the hemorrhage is such as to call 
for it. This may be removed in forty-eight hours and replaced again if 
need be. 

Irrigation twice daily with boric-acid solution is desirable, and occa- 
sionally with silver-nitrate solution (1 : 4,000) if the condition of the 
bladder calls for it. At the end of two or three days the tube should be 
temporarily removed and a sound, one or two sizes smaller than the full 
size, should be passed, after which the bladder should be washed and 
the tube replaced. 

After an interval of another forty-eight hours the same sound is again 
passed. Then, at intervals of three or four days, the largest conical steel 
sound that will go should be gently carried through the whole course of 
the urethra into the bladder, and this continued at gradually lengthening 
intervals until the wound has healed — a time generally varying from three 
to six weeks. 

The tube is left in the bladder generally for about four days, after 
which it is removed permanently, unless on account of the existing cys- 
titis it is desired to afford the bladder the benefit of prolonged drainage, 
in which case it should be left in place for ten days or two weeks. This 
necessarily makes a decided difference in the period of confinement, which 
is otherwise not generally over ten days to two weeks and sometimes less. 

After the tube is removed for the first twenty -four or forty-eight hours 
all the urine passes away through the perineal wound, after which it is 
divided in varying quantity between the perineal and the natural route. 
As the wound heals, which it generally does without assistance, the 
urine gradually passes entirely by the natural route. This sometimes 
occurs as early as at the end of the first week. 

When the patient gets about in from ten days to two weeks his peri- 
neal wound requires little care other than ordinary cleanliness and the 
protection of a pad of absorbent gauze held in place by a T-bandage. 
If after he is about there still occasionally occurs a little leakage at the 
perineal wound, it need cause no disturbance as it will take care of it- 
self, and the wound will heal firmly when the patient regains his normal 
physical tone. If a small fistula persists, it can be successfully closed by 



150 VENEREAL DISEASES. 

injecting it with the ethereal solution of peroxide of hydrogen, five per 
cent, as used in fistulous tracts elsewhere (vide p. 69). 

Finally, when the patient gets well, he must be taught to use a full- 
sized conical steel sound for himself at such intervals as may be deemed 
necessary — once a month, once in six weeks, as the case may be — just as 
after internal urethrotomy or divulsion, or his cure may not be lasting. 
Many a patient relapses into a condition of impermeable stricture, after 
having been thoroughly cut in the perineum, either because his surgeon 
has not impressed him with the necessity of using sounds or because he 
himself has been negligent in his duty. 

But recontraction is not invariable after external perineal urethrotomy. 
It is possible after the continuous and systematic use of sounds fol- 
lowing this operation gradually to lengthen the intervals between the 
passages and finally to discontinue them without recontraction of the stric- 
ture, but it is a wise precaution in all cases to advise the patient of a 
continued possibility of its recurrence and to urge him as a safeguard to 
report at long intervals — once a year or two — for exploratory examination. 

Perineal Section without a Guide. — This operation is a formidable one 
on account of the element of uncertainty which it involves. Generally 



Fig. 84.— Wheelhouse Guide. 

speaking, the operation without a guide is easy to a cool-headed surgeon, 
only a few minutes being required after the front face of the stricture is 
exposed before a passage into the bladder is obtained ; but competent sur- 
geons have worked hours before the bladder has been reached, and the 
operation should therefore not be undertaken with an undue amount of con- 
fidence, but with deliberate and painstaking precision, and under the most 
favorable conditions for an abundance of light. 

The operation calls for the same preparations as if a guide were to be 
used. Besides the other instruments a few fine probes and directors are 
also necessary. A last attempt under ether should always be made to 
pass a whalebone guide. Failing in this, the grooved sound or catheter 
or Wheelhouse guide is introduced as far as the front face of the stricture, 
entrusted, with the scrotum, to an assistant, a central incision is made as 
before, and the point of the sound exposed. When the Wheelhouse 
guide is used (Fig. 84), the incision is made upon the groove ; and after 
the urethra is opened, the staff is turned around so as to act as a re- 
tractor of the upper end of the wound. Two long silk threads, one on 
each side of the deep portion of the wound to act as retractors, are then 
passed and the loops handed to assistants. 

Now the operator, with fine whalebone or silver probe, searches cau- 
tiously on the front face of the stricture for the way of the urethra into 



STRICTURE OF THE URETHRA. 151 

the bladder. To aid him he may enlarge any existing perineal fistula, 
and try by that route to reach the posterior face of the obstruction within 
the urethra. 

Usually the best guide to the bladder is a clear anatomical understand- 
ing of just where the hole in the triangular ligament is, and in what rela- 
tion that hole stands to the lower edge of the subpubic ligament. This 
lower edge of the subpubic ligament can always be felt ; and beneath it, 
exactly in the middle line, about three-quarters of an inch below the 
symphysis, varying a little in different subjects, lies the hole in the tri- 
angular ligament. This hole is generally the operator's objective point. 
The tendency is to cut too much at first and to probe too little, until the 
operator loses his bearing in the solid mass of tissues matted together by 
prolonged inflammation ; and once fairly off the track, he rarely recovers 
his position by any other means than accident. Patient and judicious 
probing, with a little careful cutting in the anatomical position of the 
closed urethra, is generall}^ rewarded with success ; the probe soon passes 
on without obstruction for a considerable distance in the direction of the 
bladder, another probe may be pushed alongside of the first, and a separa- 
tion of these two allows a little bloody urine to flow out. The tight ring 
surrounding the probes may now be carefully followed up with the knife 
for a short distance, the area of the canal widens, a female catheter passes 
readily alongside the probes, and a gush of bloodless urine through it an- 
nounces that the bladder has been reached. 

One of the most common causes of failure in this operation is the ex- 
istence of a false passage, starting from the front face of the stricture, 
the result of some former rude attempt to pass the stricture with a solid 
instrument. The surgeon may be led far astray by such a false route, 
and find his mistake only after he has hopelessly lost his bearings among 
the diseased tissues. It is well, therefore, not to follow up any inviting 
sinus without first dilating it a little and learning whether it leads in the 
proper direction. 

After the bladder has been reached, the operation of perineal section, 
with and without a guide, are one and the same. Description of the re- 
maining steps is therefore "unnecessary, since they have been already given. 
The other surgical procedures which have been resorted to when the 
bladder is greatly distended by acute retention in the case of impermeable 
stricture are aspiration of the bladder, retrograde catheterism, and Cocks* 
operation- 
Aspiration of the Bladder. — This should be conducted under strict 
antiseptic precautions in the suprapubic region. The restricted area 
through which the needle should be passed is limited to one inch above 
the brim of the pelvis, and about one inch on either side of the median 
line. This, however, is ample space for a sufficient number of punctures 
to carry a case for several days. 



152 VENEREAL DISEASES. 

This operation is resorted to as a palliative measure in impassable 
stricture with retention, and may be followed by a decrease in the en- 
gorgement of the tissues surrounding the stricture sufficient to permit the 
passage of a small bougie or catheter, and thus open the way for a subse- 
quent external urethrotomy with a guide or for progressive dilatation. 
Cases are recorded in which on account of extensive prostatic hypertrophy 
the bladder could not be reached in the above manner. 

Retrograde catheterism is performed from the bladder through an 
opening made above the pubis, in order to reveal the opening of the 
urethra during a perineal section, when complete obliteration has oc- 
curred and a prolonged effort to find the distal end of the canal has been 
unsuccessful. 

Cocks' operation is perineal section proper, in which no guide of any 
kind is employed, not even down to the face of the stricture. 

With the finger introduced into the rectum a " boutonniere " incision is 
made toward the apex of the prostate, trusting to the deftness and 
anatomical accuracy of the operator to strike the urethra at this point. 
If the attempt be successful, a cannula is introduced into the bladder and 
retained several days, in the hope that by the relief thus afforded the 
swelling and induration about the stricture will subside to a sufficient 
extent to permit the passage of a small instrument through the contracted 
area, which if successful may be followed up by division of the stricture 
or progressive dilatation as may be deemed expedient. 

Extravasation of Urine. — Extravasation usually occurs as a result of 
rupture of the urethra during a violent straining effort to overcome the 
resistance of a tight stricture. The urine is forced into the surrounding 
tissues, being limited in its course, according to the site at which the 
rupture occurs, by the anatomical attachment of the fasciae enveloping the 
different regions. Thus when rupture occurs in the pendulous urethra it 
is followed by swelling of the penis, which may be limited within the 
fascia surrounding the corpus spongiosum, or, overcoming the resistance 
of this membrane, may extend into the connective tissues of the penis 
and scrotum. This form of extravasation is rare. 

Extravasation of urine in front of the triangular ligament through the 
bulbous portion of the urethra is limited by the attachments of this fascia 
and cannot reach the pelvic cavity or the tissues of the lower extremity, 
but is directed upward over the hypogastrium sometimes to a considerable 
extent. 

Eupture of the urethra in the membranous portion is limited by both 
layers of the triangular ligament, and on account of the great tension in 
this limited space due to the strong resistance offered by the fibrous tis- 
sues, may lead to suppuration and ulceration and a consequent fistulous 
tract through one or the other layers of the ligament into the pelvis or 
toward the perineum. 



STRICTURE OF THE URETHRA. 153 

finally rupture of the urethra behind the triangular ligament may 
lead to extravasation around the rectum in the periprostatic region, or 
going above the prostate may extend into the cellular tissues of the pelvis. 

The symptoms of extravasation of urine depend upon the locality in 
which the rupture of the urethra has occurred. The condition is self- 
evident when the extravasation occurs in front of or behind the triangu- 
lar ligament, provided the quantity of infiltrated fluid be sufficient to 
attract notice; otherwise it may pass undetected until other symptoms 
occur. Sometimes, however, the patient complains of having felt some- 
thing give way during a straining effort, followed by a certain sense of 
relief, which is unaccompanied by the normal passage of the urine. Ex- 
travasation between the layers of the triangular ligament may not be 
recognized until further extension of the process occurs or until the onset 
of constitutional symptoms. These symptoms consist of great depression 
and weakness, pyrexia and vomiting, sometimes chills ; and if the condi- 
tion continues unrelieved, the vomiting continues, the pyrexia increases, 
delirium ensues, and death may result from ursemic coma or septicaemia. 
The local symptoms consist of swellings in the region to which the 
extravasation has extended, the scrotum may be much enlarged, and the 
tissues over the hypogastrium and perineum may be tense and red or 
bluish and dusky and oedematous. Actual destruction of the tissues may 
occur as a result of sloughing or gangrene. The scrotum sloughs entirely, 
leaving the testicles bare. The more septic the urine in cases of extrava- 
sation the more rapid is the occurrence of the systemic symptoms and the 
more profound the resulting septicaemia. 

Urinary Fistula. — Small quantities of urine sometimes escape from 
the urethra, resulting in urinary abscess and the formation of fistula. 
Such abscess cavities may persist for a long time, communicating with 
the urethra. When this outlet becomes closed, a fistulous opening is 
formed in one or more places — through the perineum, backward into the 
rectum, or in front of the scrotum. 

The Treatment of Extravasation and Urinary Fistula. — Extravasation 
of urine should be met at once by active operative measures. In the first 
place the tissues involved should be drained by a sufficient number of 
incisions to relieve distention, and a proper exit for the urine should be 
provided by perineal drainage of the bladder, leaving the stricture alone 
until the constitutional symptoms subside, and the engorgement of the 
tissues IS removed as a result of the drainage established. Local cleanli- 
ness and antisepsis should be employed to disinfect the decomposing tis- 
sues, and such internal medication should be resorted to, in the form of 
stimulants and supporting agents, as will aid in sustaining the vital 
powers until the septic poison, which has disorganized the system, shall 
have been eliminated. 

The treatment of urinary abscess, whether or not it is accompanied by 



154 VENEREAL DISEASES. 

an external fistula, should consist in the formation of an external opening 
as a means of drainage, and of the establishment of the proper calibre of 
the urethral canal by dilatation or urethrotomy. Urinary fistulse, if 
found during an operation of external urethrotomy or perineal drainage, 
should be thoroughly scraped or cauterized. In many instances urinary 
fistulse will close spontaneously after the pre-existing stricture has been 
properly dilated; but it often becomes necessary to assist the healing 
process and for this purpose stimulating applications have been used m 
the form of nitrate of silver, carbolic acid, or tincture of iodine. Another 
method — and one which has proved satisfactory in the hands of the 
authors — is the use of one of the ethereal solutions of peroxide of hy- 
drogen, as employed in the treatment of fistula in connection with peri- 
urethral abscess. Some fistulous tracts, which have existed for long 
periods, are tortuous in their course, and surrounded by induration, 
may require extensive plastic work before they become permanently 
healed. 

Urethral or Urinary Fever. — Urethral or urinary fever is one of the 
accidents or complications which arise in connection with instrumental 
interference with the urethra. The phenomena constituting this condi- 
tion may be trifling or excessively severe. The simple passage of a 
catheter, the introduction even of a single smooth sound, has been fol- 
lowed by death within twenty-four hours, the patient dying with a high 
temperature following a chill of varying severity and duration. 

Septic absorption along the urinary tract is accused most commonly 
of being the cause of urethral fever, but this element alone is not the 
only causative factor of the condition in question. The position of the 
lesion, the condition of the kidneys, and individual idiosyncrasy have 
more to do with the production of urinary fever than the condition of the 
urine, be it ever so septic. The use of instruments upon some persons 
of a strongly timorous and neurotic nature sometimes gives rise to pro- 
nounced reflex symptoms. 

Thus after some trivial manoeuvre — the passage of a sound or catheter 
— the patient becomes suddenly pale and faint, sometimes losing con- 
sciousness. This same condition occurring in an individual who is the 
subject of kidney disease has been known to be followed by cessation of 
the urmary function (anuria) and death from collapse. These phenomena, 
strictly speaking, do not belong to the condition known as urinary fever, 
but are more properly considered as a form of shock. 

Chronic inflammation of the bladder and urethra and abrasions of the 
mucous membrane are predisposing factors. The harsh manipulation of 
instruments seems to act as an exciting cause, as does also the septic 
condition of the urine. Not one of these conditions alone is sufficient to 
bring on an attack. The bacillus coli communis is thought to be a com- 
mon micro bic factor, but Rovsmg has cast great doubt upon this allega- 



STRICTURE OF THE URETHRA. 155 

tion. Other pathogenic organisms probably also exercise their morbific 
influence. Operations and explorations upon the pendulous urethra and 
upon the bladder are rarely attended by urinary fever; the curved ure- 
thra is vastly the most vulnerable portion. 

Guyon recognizes three forms of urinary fever — one characterized by 
a sudden and sharp attack, rapid in its course and generally single ; second, 
an attack which is prolonged or repeated, often very intense, and which 
may be accompanied by remissions; and third, a chronic form of irregular 
duration, with or without exacerbations. The acute attack of urinary 
fever, or the first type of the acute form of Guyon, is characterized by a 
sharp chill; sometimes only chilly sensations, at others accompanied by 
marked rigors. The duration of the chill is variable, generally twenty 
or twenty-five minutes, sometimes longer. This is followed by fever, 
with an elevation of temperature of 102° to 104° F., pulse 110 to 130, 
possibly irregular, respirations more or less labored, succeeded by sweat- 
ing and general defervescence. Such an attack may occur with increased 
severity, the temperature running from 104° to 106° F., or higher, and 
the systemic symptoms being correspondingly more severe. There is 
generally a diminution in the secretion of the urine and in severe cases 
complete suppression, which, if not relieved, may culminate in acute 
uraemia and death. If the kidneys are sound, a desperate attack does not 
necessarily entail a fatal issue ; if the kidneys are diseased, the prognosis 
is much more grave. It is probable that a disorganized condition of the 
kidneys is responsible for the profound symptoms in most severe cases, 
but, on the other hand, diseased kidneys do not necessarily render a pa- 
tient unfitted for operation or prone to urethral fever. Many severe oper- 
ations are done from necessity upon the urethra and bladder of patients 
known to have defective kidneys, and they seem to escape without chill. 
Operations upon the deep urethra, when no perineal drainage has been 
established, are especially liable to be followed by severe urethral fever. 

The chronic form of urethral fever occurs in those who have chronic 
cystitis, atonied bladder, dilatation of the ureters and pelves of the kid- 
neys. The attack is generally more or less continuous, with exacerbations 
of chill and fever and gradual loss of vitality. If relief be not afforded, 
or if some additional source of irritation be introduced, such as instru- 
mental violence to the deep urethra, an acute suppression of urme may 
suddenly ensue and lead to a fatal issue. This condition is particularly 
liable to be associated with chronic cystitis the result of prostatic hyper- 
trophy, and the introduction of a catheter for the first time without proper 
precautions is often responsible for its production. The prognosis nnder 
such circumstances is exceedingly grave. When it occurs in connection 
with chronic cystitis behind an old and tight stricture, the symptoms may 
be somewhat the same as in prostatic hypertrophy; but, occurring in 
younger men, the prognosis is not so grave. 



156 VENEREAL DISEASES. 

Treatment. — The prophylaxis of urinary fever calls for the most gentle 
instrumental manipulation in connection with operations or operative man- 
oeuvres upon the urethra and bladder and a careful disinfection of all 
instruments employed. It is also important to make a careful urinary 
study of all cases under examination, in order to learn the condition of the 
bladder and of the kidneys. Internal medication as a preventive means 
is also useful previous to an examination or operation for stricture. The 
sulphate of quinine was formerly employed in full doses for this purpose, 
but is not at the present day relied upon, being commonly replaced by 
one of the internal antiseptics. Salol, from grs. xxx.-lx., may be given 
several days before and for several days following an operation. Boracic 
acid, from grs. xxx.-l. daily, is also used, or urotropin, grs. viiss. three 
times a day. At the time of the occurrence of a urinary attack during the 
chill the patient should be thoroughly covered, surrounded with hot-water 
bottles, and given a hot drink. The mild attacks are generally of only a 
transient nature, and the patient suffers from no serious after-effect. It 
is only when severe symptoms occur, such as great depression, extreme 
pyrexia, acute and continued suppression of urine, that active thera- 
peutic measures have to be resorted to. If there be evidence of acute 
inflammation of the kidneys the application of cups to the loins and 
hot vapor baths are indicated, but the most important symptom to 
note and overcome is the incomplete functional activity of the kidneys, 
amounting sometimes to positive suppression. For this condition one of 
the most reliable and satisfactory resources is the copious ingestion of 
some diuretic mineral water, such as Poland, Stafford, Bethesda, Suwan- 
nee, etc. This measure alone often results in starting the activity of the 
urinary organs and in aiding them gradually to resume their normal 
function. Urotropin, which has already been referred to (p. 94) as an 
internal antiseptic, has proved in the author's hands to be. a valuable 
agent for post-operative suppression of urine. Its action in this in- 
stance is probably due to its germicidal effect. It should be given in 
gr. viiss. doses, repeated three, four, or six times in twenty-four hours. 
Sometimes the effect is most satisfactory. The use of active diuretics 
is not generally advisable, as they are liable to exercise an irritating in- 
fluence upon the kidneys. The infusion of broom and the liquor am- 
monise acetatis may be given, and possibly render some service, but m 
the majority of cases we believe that the greatest reliance is to be placed 
upon the copious draughts of diuretic mineral water, a mild diet, prefer- 
ably of milk, and the administration of urotropin. In weak and en- 
feebled conditions stimulation and tonics are called for. Lender this 
regime the milder cases will always recover, and many of those which ap- 
pear very severe at the onset and during the attack. Those cases that 
suffer from disorganized and diseased kidneys are often beyond reach of 
any reparative measures. 



CHAPTEH VII. 

GONORRHOEAL EHEUMATISM— NON-SPECIFIC AFFECTIONS 
OF THE EYE— PURULENT OPHTHALMIA. 

GONORRHCEAL RHEUMATISM 

Occurs as a complication of gonorrhoea in both sexes. It is also found 
in connection with purulent ophthalmia. It is much more common in 
men than in women, and occurs at all ages. It bears no relation to 
ordinary rheumatism, usually involves the joints, but may attack the 
tendon sheaths, muscles, structures of the eyes, bursse, and nerves. 
Cases of gonorrhoeal pericarditis, endocarditis, and meningitis are also 
recorded. Its frequency as a complication of urethritis is not great, 
being between two and three per cent of all cases. According to the 
statistics tabulated by various authors the different joints are affected 
in about the following order of frequency : Knee, ankle, wrist, fingers, 
elbow, shoulder, hip, etc. It is more often polyarticular than monartic- 
ular. It rarely occurs early in the course of urethritis, being usually 
a late complication. It has been observed as early as the fifth or sixth 
day of the discharge, but such a case is exceptional. It is more likely to 
come on after the second or third week, and is often seen two and three 
months after the onset of the urethral inflammation. Its cause is the 
toxaemic effect of the gonococcus upon the system, either directly by its 
presence in the circulation or of the toxins derived from this micro- 
organism; or by one or the other of these morbid agencies, plus the 
action of the ordinary pyogenic microbes in the circulation, the gonococcus 
having prepared the way for their entrance. The gonococci are not in- 
variably found in the fluid obtained from the inflamed joints. It is 
believed that when the gonococci themselves are present, the character 
of the inflammation is fibrous and plastic ; that when the joint effusion 
is purulent, pyogenic organisms are present. The pathological lesion in 
the joints consists of a synovitis, which may be serous, plastic, or puru- 
lent. A common form of this malady is hydrarthrosis, which often 
attacks the knee-joint. It generally occurs on one side, assumes a 
chronic form, and shows a tendency to relapse during subsequent attacks 
of urethritis. 

Symptoms. — There is nothing distinctly characteristic in the symptoms 
of gonorrhoeal rheumatism. The condition may be acute, subacute, or 
chronic. The local manifestations may be monarticular or polyarticular. 



158 VENEREAL DISEASES. 

When tlie affection is acute and a single joint is involved, for example 
the knee, the joint becomes swollen and painful as in ordinary rheuma- 
tism, and there may be some slight febrile symptoms. Local pain is 
decidedly increased by moving about. When the effusion is of a plastic 
character the symptoms are more marked; and still more so when the 
inflammation becomes purulent. In polyarticular gonorrhoeal rheumatism 
the symptoms are not increased in proportion to the number of joints in- 
volved, and the intensity of the inflammation is not more marked in this 
form of the malady. 

The symptoms of gonorrhoeal rheumatism may be Very mild, simply 
amounting to a little stiffness of the joints on moving, especially in the 
morning. On the other hand, a much more intense condition may arise, 
occasioning considerable spontaneous pain in the affected joints, with 
redness of the skin and swelling, presenting all of the features of ordi- 
nary rheumatic gout. The affection generally tends in a few days to 
become subacute in character and then to assume its customary march, 
which is one of tiresome chronicity. It is usual for several joints to 
become involved consecutively, but the trouble continues in the old joints 
and does not leave them when the new ones are invaded. 

Another form assumed by gonorrhoeal rheumatism is inflammation of 
the muscles, sheaths of tendons, bursse, and nerves. These affections 
also tend to become chronic, a number of weeks or even months some- 
times elapsing before they are brought under control. The bursse most 
often implicated are located under the tendo Achillis, under the inferior 
tuberosity of the os calcis, in front of the patella, and behind the olec- 
ranon. These tendon and bursal affections may assume an acute, sub- 
acute, or chronic character, and are apt to be found complicating the 
polyarticular form of gonorrhoeal rheumatism. 

The diagnosis of gonorrhoeal rheumatism depends upon the pre-exist- 
ence of urethral inflammation, which would naturally suggest the nature 
of the malady, the mild systemic reaction and febrile disturbance as com- 
pared with acute inflammatory rheumatism, and the tendency of the af- 
fection to become chronic. There being no connection with ordinary rheu- 
matism the rheumatic diathesis is likely to be absent. The larger joints are 
favorite sites of this malady, and hydrarthrosis is a not uncommon form. 

Prognosis. — As already stated, the general tendency of this malady is 
toward chronicity, relapses occurring in connection with subsequent at- 
tacks of urethral inflammation. The duration of the active period of the 
disease is generally rather long, and increased in proportion to the num- 
ber of joints attacked. When the effusion is .plastic or sero-purulent the 
case becomes thereby so much the more protracted and the function of the 
joints is more likely to become impaired or abolished. 

Cardiac complications are alway serious and may lead to a fatal issue. 

Treatment. — The treatment of gonorrhoeal rheumatism comprises meas- 



NON-SPECIFIC AFFECTIONS OF THE EYE. 159 

ures directed against the urethral inflammation and those which are 
applied to the arthritic complication. It is most important that the 
urethral condition should be properly treated, as upon the success of such 
treatment may depend the improvement in the rheumatic affection. 
Nitrate of silver is a favorite local application for the urethra, and if 
there be a free amount of purulent secretion, either forward in the ure- 
thra in the form of a discharge or backward into the bladder as shown by 
the urine, irrigations of nitrate of silver into the bladder, 1 :4,000, or of 
the permanganate of potassium, 1:6,000, or of corrosive sublimate, 
1:12,000, may prove more effective than instillations of silver, which 
are generally more suited to cases in which the focus of the urethral 
trouble appears to be confined to a small area. In the latter instance the 
nitrate of silver in the form of deep urethral instillations by the method 
already described in the section on chronic urethritis may prove satis- 
factory. Balsams and alkalies are of little value. Opium should be given 
in some form if the pain demands it. Salicylate of sodium, oil of gaul- 
theria, or iodide of potassium may be given in proper doses, sometimes 
with apparent benefit. The plan of drinking freely of a diluent mineral 
water is the best means of correcting the tendency of the urine to become 
scanty and highly concentrated. The local measures called for by the 
joint itself consist, in the first place, in absolute rest. Cold evaporating 
lotions in most cases and flaxseed poultices in others are suitable expedi- 
ents and the means of securing a certain degree of comfort. When the 
acute condition has subsided, the remaining trouble in the joints, tendons, 
and bursse should be treated by friction, massage, gal vano -cautery, electro- 
massage, dry heated air, blisters, and such other methods as are generally 
resorted to for the removal of inflammatory deposits and the treatment of 
dry arthritic conditions under other circumstances. Suppuration in the 
joint may require aspiration or drainage, and may ultimately end in im- 
pairment of the joint structure and lead to permanent ankylosis. 

NoN- Specific Affections op the Eye 

During the course of polyarticular gonorrhoeal rheumatism or alternat- 
ing with it, during different attacks of urethral inflammation, affections 
of the eye have also been noted. They involve the iris, conjunctiva, 
sclera, and cornea. These ocular affections are m no sense due to con- 
tagion, but occur m the same manner as the arthritic inflammations and 
appear as complications of them. They get well without compromis- 
ing the structure of the eye or its function, but are liable to relapse dur- 
ing subsequent attacks of urethral inflammation. When the eye is 
attacked by this non-purulent form of inflammation in conjunction with 
urethritis, the cornea becomes somewhat cloudy and is apt to grow more 
promment from overdistention with fluid. The iris is likely to be the 



160 VENEREAL DISEASES. 

main seat of the trouble, although it does not show much change in color. 
The pupil may be slightly dilated and irregular or normal. The move- 
ments of the iris are partially or entirely abolished. The conjunctiva 
alone may be the seat of an injection, which is marked by a slight redness 
and swelling, some uneasiness, or perhaps by no pain at all, and a scanty 
muco-purulent discharge. This should not be confounded with the viru- 
lent contagious form or ophthalmia. All of these affections of the eye are 
distinguished from the virulent form, due to contact with gonorrhoeal 
pus, by the great intensity of the symptoms in the latter malady. 

The treatment of the eye affections which occur as complications de- 
pends upon the nature and extent of the inflammatory condition. If the 
conjunctiva alone is involved, it may be sufficient to cleanse the eye fre- 
quently with a proper lotion consisting of normal salt solution or a solu- 
tion of one grain of sulphate of zinc to the ounce of camphor water, and 
the use of a shield to protect the eye from the light. If the deeper struc- 
tures of the eye are attacked, involving the distention of the anterior 
chamber, the latter may require tapping. When the iris is involved, 
instillation of a solution of atropine should be used daily to keep the 
pupil dilated. In more severe attacks, when the inflammation becomes 
intense, a leech may be applied to the temple or a blister behind the 
ear. Anodynes should be administered in proper quantity. In chronic 
cases the condition of the patient generally calls for the use of tonics, 
change of air, and a nutritious diet, which course should be rigorously 
adopted for obvious reasons. 

GONORRHCEAL OPHTHALMIA. 

This virulent inflammation is always due to the direct transference of 
gonorrhoeal pus from the diseased urethra to the eye, perhaps the 
patient's own eye, perhaps the eye of another, It also attacks the eyes 
of infants, having been acquired during birth from gonorrhoeal pus in 
the vagina. 

In most instances this affection is the result of carelessness on the part 
of the patient, who failing to exercise proper precautions in cleansing the 
hands after handling the genitals, either in a moment of thoughtlessness 
or during sleep, infects one or both eyes by the contact of the fingers. 
The surgeon is guilty of contributory negligence who does not impress 
upon the patient the danger of contamination and the importance of ab- 
solute cleanliness of the hands after handling the penis infected with 
gonorrhoea. The gonococci are the causative factors of this virulent in- 
flammation. There is said to exist a milder affection caused by inocula- 
tion with some of the pyogenic microbes obtained from vaginal or urethral 
discharges which are not gonorrhoeal. 

Fortunately, gonorrhoeal ophthalmia is rare, doubtless due to the fact 
that the danger to the eye of contact with gonorrhoeal pus is quite gener- 



GONORRHCEAL OPHTHALMIA. 161 

ally understood. The disease is not often double at tlie start, but it is 
very apt to become so during its course, unless great care be taken to 
shield the well eye while the other is being treated. 

Symptoms. — Within a few hours after contagion the eye feels dry and 
itching, as if sand were beneath the lids. The eye waters a little from 
the start, and the conjunctiva promptly becomes red, the lids slightly 
oedematous. 

The pain, swelling, and discharge increase with alarming rapidity. 
The upper lid swells so much and so rapidly that it soon completely 
covers the lower lid, and lies out prominently upon the cheek, red and 
oedematous. 

The conjunctiva beneath is the seat of oedematous swelling. It be- 
comes highly vascular, looking raw, sometimes livid in color, raised into 
a thick border around the cornea (chemosis), which lies at the bottom of 
the cavity formed by the swollen conjunctiva, generally bathed in pus. 

The pus, green and thick, flows out abundantly upon the cheek, thinned 
from time to time by a gush of tears, sometimes tinged with blood. The 
lids partly stick together with the thick incrustations of matter which 
incessantly flow away. The epithelium upon the cheek becomes sodden 
and perhaps excoriated with the acrid secretions. 

The cornea soon gets into difficulty from strangulation by the chemo- 
sis. It becomes at first infiltrated, then softened at the edge at points 
underlying the swollen conjunctiva, and so rapidly do the morbid changes 
occur that within twentj'^-four hours from the commencement of the affec- 
tion the cornea may have ulcerated to the point of perforation. Abscess 
may form in the cornea and discharge externally, followed shortly by a 
giving way in the posterior wall of the abscess, which allows the fluid to 
escape from the anterior chamber and the iris to protrude at the opening. 
Again, the whole cornea may ulcerate peripherally and drop out like a 
watch-glass, and this may be followed by an escape of the crystalline lens 
and suppuration, with destruction of the entire contents of the globe. 

Meantime, pain is often most intense and photophobia extreme. The 
pain is felt not only in the eye but all around it. There may be little or 
no fever (unless the globe suppurates), but profound depression is the rule. 
A sense of some impending catastrophe seems to overwhelm the sufferer. 

The diagnosis and prognosis of gonorrhoeal ophthalmia depend upon 
the presence or absence of the gonococci in the discharge from the eye. 
Other forms of virulent ophthalmia may be so intense as to simulate 
strongly the gonorrhoeal form. The microscope will settle the question 
beyond doubt and should always be resorted to at the onset of the malady, 
as the prognosis of gonorrhoeal ophthalmia always depends upon its early 
recognition and prompt and vigorous treatment. 

The less virulent form, not due to gonococci, is not a grave disorder, 
and much less likely to lead to the serious consequences which are so sure 
11 



162 VENEREAL DISEASES. 

to follow rapidly in the wake of an untreated attack of true gonorrhoeal 
ophthalmia. In this latter case the prognosis given should always be a 
grave one. When active treatment is established at the onset of the 
inflammation the chances of recovery are good, while the restoration of 
the sight in one or both eyes is exceedingly doubtful after ulceration of 
the cornea has occurred. Incomplete destruction of the structure of the 
eye may leave the eyesight only partially impaired, and deformities may 
remain which are amenable to operative treatment. 

Treatment. — When one eye is found to be the seat of contagious puru- 
lent ophthalmia, it becomes the physician's duty immediately to protect 
the other eye. 

The curative treatment of purulent contagious conjunctivitis rests 
upon cleanliness, relief of strangulation, and arrest of suppuration. 

Cleanliness must be maintained through the whole course of the affec- 
tion. Frequent application of cold compresses is to be practised, and 
the discharge continually washed away with saturated boric-acid solution 
or corrosive sublimate, 1 : 10,000. These washings may be repeated, with 
advantage hourly, or at such intervals as may be called for by the accu- 
mulation of pus. Anything that touches pus from the eye should be 
burned and the nurse cautioned to preserve her own eyes against contagion, 
preferably by wearing protective spectacles. 

Thin compresses, soaked in iced water and constantly changed, should 
be applied to the eye. A night nurse, as well as a day nurse, is called 
for to perform this arduous task. The constant application of cold to the 
eye is of great importance, and the means which can effect this most 
continuously should be employed. Small quantities of pounded ice, tied 
in a piece of rubber tissue, serve well in most cases, but after the vitality 
of the cornea is threatened and ulceration has commenced, it is well to 
be prudent in the use of ice or to suspend it altogether. 

Among the local applications used with the view of keeping down 
pus formation, the nitrate of silver in solution holds the first rank. It 
is of value when the pus begins to be freely formed, and the strength of 
solution employed, as well as the frequency of the applications, is decided 
by the violence of the flow of pus and by the effect of the applications 
upon it. It is best to use the nitrate of silver in solution, on account of 
the difficulty of touching all parts of the inflamed conjunctiva with the 
solid stick. It is well to employ two solutions . one quite mild, from 
three to six grains to an ounce of water, to be applied every two or 
three hours ; and another, much stronger, from ten grains up to a drachm 
in an ounce of water, to be applied at intervals when the secretion of pus 
becomes too considerable to be held at all in check by the milder solution. 
The strength of the caustic solution of course must be regulated by its 
effect upon the pus-forming process. If a reasonably mild solution will 
hold it in check, so much the better ; if not, recourse may be had at each 



GONORRHCEAL OPHTHALMIA. 163 

application, after an interval of eight to twelve hours, or longer if the 
solution is quite strong, to a solution of greater strength, until the de- 
sired eifect has been attained, after which the intervals between the 
applications may be lengthened or their strength diminished. 

In making applications of the nitrate of silver to the conjunctiva, the 
lids should be everted as much as possible, and the application made in 
the main upon the palpebral conjunctiva; that upon the globe is of less 
importance, and every effort should be made to avoid getting any of the 
solution upon the cornea already devitalized by the strangulation of the 
vessels supplying its nourishment, and especially since it may permanently 
discolor the cornea. The conjunctival culs-de-sao stand in especial need 
of the applications, which can hardly be made too thoroughly at these 
points. After each application of the nitrate of silver the eye should be 
freely brushed over with a strong salt solution to neutralize all excess 
of the nitrate of silver which may remain in the eye. Cold compresses 
upon the eye after each application of caustic will help to allay the pain. 

When the conjunctiva and lids swell much, the eye suffers from ten- 
sion in two ways : by the tightness of the tarsal border which irritates 
the eye and prevents a free outflow of the discharges, and by the chemo- 
sis of the conjunctiva which strangulates the cornea. Both of these 
strangulations may and should be relieved, the first by freely cutting 
the outer canthus, enlarging the palpebral slitj the second by deep and 
thorough scarification of the chemosed conjunctiva. 

The cornea requires especial attention. The cup at the bottom of 
which it lies should be washed out, aud the edge of the cornea all around 
under the overhanging chemosed conjunctiva should be frequently in- 
spected, to detect the commencement of abscess, or of the ulcerative 
process. As soon as rupture of the anterior chamber seems imminent, 
the escape of the fiuid should be anticipated by paracentesis of the cornea, 
and the incision should be kept fistulous, if possible, by the use of a fine 
probe, until the cornea is out of danger. 

A solution of atropine should be dropped into the eye several times 
a day from the first. It tends to diminish intra-ocular tension, to reduce 
pain, and to keep the iris out of harm's way, either from adhesion or 
from prolapsing into any fortuitous opening in the cornea, due to the 
perforation of an ulcer. Should such prolapses occur, any portion which 
projects may be cut away. Adhesion of the iris to the cornea at the point 
of piolapse is quite certain to take place, calling perhaps for iridectomy 
when the patient recovers. 

As the eye begins to recover, it must be shaded from the light and 
tenderly nursed for a long time. The lotions of nitrate of silver may be 
gradually reduced in strength, and finally substituted by mild solutions 
of sulphate of zinc, or alum, or by normal salt solution. An eye may 
come out of the contest much damaged, but yet capable of being nursed 



164 VENEREAL DISEASES. 

up to the point of being of considerable use to its possessor. In bad 
cases vision is totally destroyed. 

Tlie internal treatment should be supporting and tonic throughout, 
all the energy of the treatment being devoted to the local measures. 
Mercury, up to the point of producing salivation, has been advised in bad 
cases in vp'hich there is a diphtheritic tendency, but the suggestion by no 
means receives the uniform indorsement of authorities, and is of ques- 
tionable propriety, certainly so far as regards a majority of the cases 
seen in cities where the vitality of the individual is not high. The 
malady itself is unquestionably very debilitating, and tonics and good 
food are called for more than any other internal remedies. Laxatives 
are usually required, with a judicious use of anodynes to insure sleep 
and control pain. 



PART II. 

CHANCROID AND SYPHILIS. 



CHAPTER I. 

CHANCROID. 
Definition, Etiology, and Clinical History. 

Definition. — Chancroid is a virulent ulcer, purely local in character. 
It is always due to inoculation of the surface with pus derived from a 
similar ulcer, and its own secretions are freely auto-inoculable. 

These characters are cardinal and uniform. Clinically, a chancroid 
does not exist which does not fulfil each of these conditions. This state- 
ment applies to the genuine type of this local venereal sore. The name 
of chancroid is sanctioned by long usage and generally adopted in this 
country. It is otherwise spoken of as the "soft chancre," as distin- 
guished from the "hard chancre," or primary syphilitic lesion. These 
latter names are to be discouraged for general usage as they imply dis- 
tinctive characteristics — " soft " and " hard " — which are not invariably 
to be found in all instances of these two lesions, but on the contrary are 
sometimes reversed. The fact should not be lost sight of, however, that 
the characteristic of " hardness " or induration generally belongs to the 
structure of the " syphilitic chancre, " and that the existence of a condi- 
tion simulating it, in connection with chancroid, is exceptional. 

Chancroid possesses an individuality as clear and distinct as either of 
the other venereal diseases — gonorrhoea and syphilis. The history is not 
so ancient which relates how it successfully passed through one era of 
obscurity, during which it was attempted to merge the two distinct dis- 
eases, chancroid and syphilis, into one family. This one time vexed 
question has been settled beyond all doubt or cavil. No possible relation 
exists between these two maladies, as was demonstrated by the energetic 
campaign inaugurated by Eicord and culminated by Bassereau. 

An attempt to trace the history of chancroid has given occasion for 
the display of much erudition. No author has been more painstaking in 
this direction than Bassereau, ' who brings out evidence from the writings 
of ancient Greek, Latin, and Arabian surgeons which establishes the 
presumption that contagious venereal ulcers have existed from all time ; 
and that some at least of these ulcers were chancroidal, it is hardly rea- 
sonable to doubt. 

Description. — A typical chancroid, unirritated and uncomplicated, is 

'"Traite des Affections de la Peau symptomatiques de la Syphilis," Paris, 
1852, p. 217 et seq. 



168 VENEREAL DISEASES. 

a rounded ulcer. In a furrow it is oval, large or small, single or multi- 
ple, simple or composed of several ulcers which have run together. A 
faint pink areola surrounds its edges which are abrupt, sharply cut at 
right angles to the surface (not sloping away), and very often under- 
mined, because the superficial integument resists the advance of the 
spreading ulcer a little longer than the less dense underlying structures. 
The bottom of the ulcer is either pallid, with pink granulations, bathed 
in thick pus, or, more often, pultaceous, yellow, looking like dirty cream ; 
and this surface, composed of sloughy structures, permeated with pus, is 
adherent, and blood flows on any attempt at its removal. The base of 
the ulcer can be easily lifted up from the tissues beneath, and, although 
consisting of an inflammatory oedema, when rolled between the thumb and 
finger presents no marked* rigidity. 

The pus is creamy and freely secreted from the ulcerated surface, and 
contains the broken-down detritus of the anatomical elements which have 
been involved in the progressive march of the destructive ulcer. There 
may be no pain associated with it except from handling or friction, or 
during erection. 

Such is the simple clinical chancroid as seen in a typical case. Com- 
plications, however, may attend it and subject its appearance to varia- 
tions. The more it differs from this type, the less possible is it for the 
surgeon to be positive in his diagnosis. 

It is therefore of the first importance, in the study of venereal dis- 
ease, to comprehend what a chancroid is and to what variations it is 
liable, especially in these modern days when every ulcer produced by 
inoculation finds some sturdy advocate ready to proclaim it a chancroid. 

Varieties. — The typical chancroid, as described above, is generally 
superficial and round, or may be unsymmetrically irregular on account 
of the sitaation, or the shape of the abrasion or fissure inoculated, or on 
account of the running together of several chancroids of different sizes, 
in which case its border is irregular and uneven. This is the exulcerous 
lesion. Multiple chancroid of the anus is stellate. 

Instead of being an open ulcer, chancroid sometimes remains scabbed 
over. The thick pus dries up on the surface, but continues to be formed 
beneath the scab^ from the sides of which it oozes under pressure. It 
advances by the formation of new rings of pus under the epidermis 
around the old scab, and generally has a livid areola outside of all. It 
is by no means common, is called ecthymatous chancroid, and is more apt 
to be found on the integument. Lift off the crust in such a case and the 
characteristic ulcer will be revealed. 

In fotliciUar chancroid, infection takes place through the mouth of a 
healthy follicle. It is a clinical sore, and cannot be produced artificially. 
Inoculation takes place beneath the plane of the surface, and if the 
latter happens to be tough it retains its integrity for a considerable 



ETIOLOGY OF CHANCROID. 169 

period. When first seen it is a large acuminated pustule which varies in 
size, and is full of thick pus. Suppuration tends to spread peripherally 
beneath the epidermis until the latter has broken or is cut away, when the 
typical chancroid is disclosed. The incubation period of follicular chan- 
croid is naturally long. 

The base of an unirritated chancroid is soft. If inflamed from irrita- 
tion, it becomes hard, indurated, and elevated above the surrounding 
plane. In this form it is spoken of as the ulcus elevatum. This indura- 
tion sometimes cannot be distinguished with certainty from the induration 
of syphilitic chancre. Generally, however, the difference is striking. 
The induration of chancroid is manifestly an inflammatory affair. The 
integument is discolored for a certain distance around the edge of the ulcer, 
with a distinct inflammatory blush. The edge of the induration is not 
sharply defined, but fades away insensibly into the surrounding tissues. 
Pressure upon the induration causes pain. The typical induration of a 
syphilitic chancre is a tense, elastic, insensitive, non-adherent, sharply 
defined underlying induration so familiar to the fi.ngers once accustomed 
to it, and yet so difiicult to be certain about in all cases in which it is im- 
perfectly developed. The induration of syphilitic chancre often precedes 
the ulcer, or occurs simultaneously with it. That of chancroid always 
follows the ulcer. 

When the inflammation of chancroid is intense and rapidly attacks the 
surrounding structure, causing sloughing or gangrene of the tissues, it is 
Q,2iWedi phagedenic chancroid ; and when it becomes more or less chronic, 
is continuously progressive and irregular in its course, sometimes healing 
in one portion while it extends to another, it is called serpiginous. 

Pathological Histology. — The minute structure of chancroid, as re- 
vealed by the microscope, presents nothing peculiar. The tissues of the 
cutis and of the epidermis are swollen, the adventitia of the' blood-ves- 
sels is dense, and the walls of the capillaries are thickened. The area in- 
volved by the ulcer is infiltrated with round cells crowded together in 
the meshes formed by separation of bundles of connective tissue. This 
infiltrate extends into the tissues beyond, involving the neighboring 
papillae. The ulcer rests upon a bed of inflammatory oedema^ its floor 
is unevenly dented with rounded or rugose granulations and covered with 
a membranous pellicle. Like the blood-vessels the lymphatics are in- 
creased in number, and their openings present upon the surface of the 
ulcer. 

Etiology. — The true nature of the poison of chancroid has not been 
revealed. Different observers have endeavored to discover the specific 
micro-organism which is the essential cause of chancroid, but no con- 
vincing demonstration has yet been given of its discovery, and the pro- 
fession to-day is as ignorant upon this subject as it is also of the specific 
microbe of syphilis. There is a growing tendency to disclaim the exist- 



170 VENEREAL DISEASES. 

ence of a distinctive poisonous quality in chancroidal pus. E. W. 
Taylor/ of New York, in conjunction with his lat<» colleague, Dr. Bum- 
stead, who years ago read an able paper" before the International Medi- 
cal Congress on this subject, and several other well-known authors, have 
advanced the doctrine that the inoculation of the products of simple 
inflammation may produce chancroids notably upon persons who are 
syphilitic or much debilitated. 

But why an ulcer, let it resemble a chancroid perfectly — produced 
upon a person in a healthy or debilitated condition by the inoculation of 
indifferent inflammatory pus — should be called a chancroid, even although 
the pus be repeatedly auto-inoculable, is difficult to understand. The 
auto-inoculability in generations of pus simply confirms the well-known 
fact that all pus is more or less septic. 

If chancroid could be produced de novo by the inoculation of ordinary 
pus, the number of chancroids clinically observed upon respectable people, 
and those syphilitic, cachectic, or otherwise, would be vastly greater than 
it is. 

Those who dissent from the opinion that the chancroidal ulcer is not 
caused by a specific virus do so on the ground that inoculation with pus 
containing ordinary micro-organisms may produce a sore indistinguishable 
from chancroid, and one which is auto-inoculable j that the common pyo- 
genic microbes are always found in chancroidal ulceration, and that the 
existence of a special organism has never been satisfactorily demonstrated. 
On the other hand, it may be stated that chancroid has distinctive quali- 
ties which cannot be explained by the " peculiarities " of the tissues upon 
which it is found. It is always highly contagious, much more virulent, 
and its pus more freely inoculable than that of other ulcerations. So 
great is its virulence, it has been found, that even after considerable dilu- 
tion its contagious element remains. Puche with a drop of chancroidal pus 
diluted in a half glass of water has produced a typical chancroidal ulcer. 

The existence of specific urethritis c^n hardly be denied on the ground 
that there exists a non-specific inflammation closely resembling it, yet this 
ground is taken to deny the existence of a specific element in chancroid. 
While the ordinary pus organisms may be found in every instance of 
chancroidal sore, some observers claim to have found in addition in all 
cases examined by them a distinctive microbe. The failure to produce 
conclusive testimony regarding the specific nature of such a micro-organ- 
ism might well be due to the lack of the suitable culture medium. It 
was for a long time impossible to obtain a pure culture of the gonococcus 
on this account, and it is only of recent years that it has been satisfac- 
torily accomplished. Finally, when the chancroid is thoroughly cauter- 

' "Venereal Diseases," Lea Brothers, 1895. 

2 Transactions of the International Medical Congress, 1876. 



ETIOLOGY OF CHANCROID. 171 

ized early enough in its life to include in the slough all of the infected 
tissue, a healthy granulating sore is left, which ceases to be destructive 
and loses its intensely inoculable quality. 

Various writers hold opposite views on this subject. Taylor in this 
country stands in strong opposition to the belief that a special microbe 
is responsible for the existence of chancroid, and holds that it is due to 
the ordinary pus organisms found in all suppuration. Finger, of Ger- 
many, is apparently in accord with the views of Taylor. Martin,' of 
Philadelphia, writing upon chancroid in 1893, stated that the question 
was still suh jiidice, but that ultimately the specific microbe would be 
found. A later work, in which he is an associate author, at the opening 
of this subject states: "It is generally accepted that chancroid is a 
simple ulcer caused by the inoculation of the well-known pyogenic mi- 
crobes," and further along that the question is "still in doubt." 

The early writings of Fournier, Keyes,^ and others record their be- 
lief, as a result of exhaustive study on the subject, that chancroid is a 
distinctly unique local venereal sore due to a specific poison, and at the 
present time these authors, while accepting the premises adduced by op- 
ponent thinkers, that pus obtained from simple ulcerations and pustules 
is often freely inoculable, have not found sufficient reason to alter their 
views. 

A number of serious workers and scientific investigators express their 
convictions on the subject more definitely in describing an organism which 
they have isolated and studied, and believe to be the specific microbe 
of chancroid. One of the earliest of these, Ducrey, ^ describes an organ- 
ism found by him constantly in the discharge of chancroid, which was 
also found by Unna* in the lymph spaces. Other workers on the same 
lines confirm their results. 

The organism in question is a streptobacillus, being a rod-shaped 
body with rounded extremities, which is grouped for the most part in 
chains. It has never been successfully cultivated, possibly for want of 
a suitable medium, and therefore a pure culture has not as yet been 
obtained. 

At the present writing it must be admitted that the evidence in favor 
of this being the specific micro-organism of chancroid lacks convincing 
demonstration. 

Inoculahility. — The inoculability of true chancroidal pus is virulent 
and rapid. Such pus takes at once upon the person bearing the sore. 



^ Morrow: "System of Gen i to-Urinary Diseases," etc.; White and Martin. 
" Genito-Urinary and Venereal Diseases," Philadelphia, 1898 

2 "Venereal Diseases," William Wood and Company, 1880. 

^Comptes Rendus du Congres Internat de Derm, et de Syph., Paris, 1889, 
p. 229. 

^ Monatschrift fiir prakt. Dermat., vol. xiv., 1892, p. 485. 



172 VENEREAL DISEASES. 

demonstrating its auto-inoculability in an unmistakable manner. The 
healthiest individual may be made the subject of experiment — an ex- 
periment always successful unless the capacity of the tissues to respond 
has been overcome by prolonged inoculations as in syphilization. A 
chancroid is not indefinitely auto-inoculable ; the capacity of the skin 
to furnish ulcers upon local irritation of the proper sort has its limit. 
The early investigators were too positive in their statements about chan- 
croidal pus. Truly it is very virulent. A patient in high fever (typhoid) 
will take it ; cancer, leprosy, a previous chancroid, none of these prevent 
a take if chancroidal pus be properly inoculated j but the " syphilizers " 
have clearly demonstrated that the skin may be worn out in its capacity 
of responding to the repeated inoculation of chancroidal or other pus. 
After a period of rest the skin will act again upon inoculation, and the 
patient then may be repeatedl}'" inoculated until again the inoculation will 
no longer take. Syphilization or repeated inoculations with pus pre- 
sumed to be syphilitic, is a practice introduced at a time when the dis- 
tinction between chancroid and chancre was not generally recognized, and 
was employed in the hope of preventing the development of syphilis by 
producing an immunity of the skin against the absorption of the syphilitic 
virus. 

Different parts of the body show a varying susceptibility to the inocu- 
lation of the chancroidal virus. The thighs are more susceptible than is 
the abdomen, and the face is less so than either one of these other regions. 

Although the chancroid is an auto-inoculable ulcer, an auto-inoculable 
ulcer is by no means necessarily chancroid. Pus which is not chancroidal 
may be re-inoculated upon another person, or may produce a series of 
auto-inoculable ulcers upon the same individual. A great difference also 
is found in individuals — some take easily, some with difficulty, some not 
at all. Syphilitic and cachectic persons form the best subjects for inocu- 
lation, A syphilitic chancre which is irritated into suppuration may 
also be auto-inoculable, producing a pustule or an auto-inoculable ulcer 
(non-syphilitic) . Here it is evidently the pus which is the inoculating 
agent and not the secretion of the chancre. A syphilitic chancre of pure 
type does not suppurate at all, and the inoculation of its serous discharge 
does not produce an auto-inoculable ulcer. There is nothing strange in 
the fact that chancres irritated into suppuration become auto-inoculable 
since the pus of scabies and the pus of ecthyma have the same effect. 

Then, again, the discharge of an inflamed syphilitic chancre by 
*' hetero-inoculation " upon a healthy subject may produce nothing, or a 
simple ulceration or pustule in the same manner as above. 

These facts are adduced as arguments against the claim that chancroid 
is dependent upon a specific virus, but they illustrate only the generally 
accepted teaching in regard to all pus. It has been demonstrated that 
chancroid may be transmitted by inoculation to the lower animals, and 



ETIOLOGY OF CHANCROID. 173 

that the poison which develops there may be carried back again and suc- 
cessfully inoculated in man. 

As in the human subject, repeated auto-inoculation in animals soon 
results in a temporary immunity against reproduction of the ulcer. 

Relative Frequency, — Statistics drawn from hospital and dispensary 
experience show that among the class of patients who frequent these 
institutions the frequency of chancroid is far greater than that of syphi- 
litic chancre. In private practice, however, this order of the frequency 
of chancre and chancroid is reversed. Herpetic troubles are certainly 
more common on the whole than either chancre or chancroid, and are 
frequently mistaken for the latter. 

The conclusion is, as Fournier has pointed out, that the greater care 
and neatness exercised by the higher classes protect them in a measure 
from chancroid, but offer no guaranty against infection by the seemingly 
less formidable primary lesion of true syphilis. This conclusion becomes 
especially obvious on considering the fact that mucous patches, which 
may lie concealed high up in the vagina and last for months at a time, 
are as capable of communicating syphilis as is the true syphilitic chancre. 

Manner of Contagion. — Chancroids develop only from contact of chan- 
croidal pus with a surface deprived of epithelium. 

There are two exceptions to this rule, one in which chancroidal pus is 
placed upon a healthy surface, remains there undisturbed, erodes the 
epithelium by virtue of its acridity, and thus prepares a way for the 
absorption of the virus, and the other in which a little chancroidal pus 
gets into the mouth of a healthy follicle (see Follicular Chancroid) . The 
period of incubation in both cases is unusually long. 

The methods of contagion are two, direct and mediate. 

In direct contagion the source sujjplying the pus and the part inocu- 
lated come into direct contact. This is the usual way. In sexual inter- 
course, when a chancroid upon an individual inoculates a portion of over- 
lying contiguous integument, when a fissure on the physician's finger 
becomes contaminated while practising the vaginal touch — these are 
instances of direct contagion. 

Mediate contagion means that there is an intermediate carrier of the 
pus which receives it from its source and deposits it where it finally takes 
root. The vagina may be the medium of contagion receiving the pus from 
one man to give it up to another immediately without itself becoming 
contaminated, but this must be rare. The prepuce may play a similar 
intermediate part. The lancet of the surgeon gives rise to mediate con- 
tagion in cases of inoculation. 

The pus of chancroid remains virulent until the ulcer is healed, but 
decreases in virulence toward the end. Frozen and corked up in bottles, 
the pus retains its virulence for a long time (Boeck). Boiling heat, 
acids, alkalies, corrosive sublimate, alcohol, decomposition — all destroy 



174 VENEREAL DISEASES. 

the virulence of the pus. Boeck believes that dried pus is inert; Sperino 
taught the contrary. 

Inoculation is spoken of under two heads — auto- and hetero-inoculation. 
Auto-inoculation is the inoculation of the patient with the secretion of 
the chancroid he himself bears. This may be effected purposely -as a test 
by the surgeon. It may take place by contact of adjacent surfaces. In 
such a case it is called spontaneous auto-inoculation. Auto-inoculation 
as a diagnostic test is not so commonly employed now as it was formerly. 
As a test it is thought to be deceptive, since so many other kinds of 
pus produce ulcers upon some persons. These latter ulcers are not chan- 
croids, but they secrete pus and are apt to deceive. 

Yet auto-inoculation is still an excellent resource in some cases, the 
frank take of the true ulcer being very characteristic and always easy to 
obtain upon a fresh subject — a fact which cannot be affirmed to the same 
extent about any other kind of pus. 

A point suitable for auto-inoculation for diagnostic purposes is the 
breast below the nipple. A true chancroid will undoubtedly always take 
here, but the resulting sore is not apt to be troublesome, and phagedsena 
is almost unheard of in this region. 

Hetero-inoculation is the inoculation of pus from one patient to 
another, as practised by syphilizers. Chancroid, as found clinically, is 
also the result of hetero-inoculation. 

Clinical History. — Probably, changes in the tissues commence im- 
mediately upon contact of the virus with a denuded surface. By the 
end of twenty -four hours the inoculated point is distinctly red, during the 
second or third day a pustule forms, and generally by the third day, if 
the pustule be broken, a fully formed typical chancroid is found, with its 
abrupt margin, suppurating floor, soft base, pink areola, etc. When first 
found by the patient, it is generally aheady an ulcer or an exulcerated 
fissure. Sometimes it is a pustule. 

Clinically the incubation period of chancroid should be placed at two 
or three days, very rarely longer. It may reach a week, possibly ten 
days in cases of follicular chancroid, or when the pus has been deposited 
upon unbroken epithelium and has to erode its way through before it 
can take effect. Sometimes the ulcer is not found by an unobservant 
patient until many days have elapsed, because it has caused no paia and 
has not attracted attention. 

Uncomplicated chancroid tends to run through three defini^ periods : 
the period of increase, the stationary period, the period of repair. 

Period of Increase. — This lasts one or two weeks, occasionally a little 
longer. The ulcer preserves its characteristic features as it increases in 
size. It generally stops when it reaches about one-fourth of an inch in 
diameter, but may rapidly spread to the diameter of an inch or more. 

Stationary Period. — During about two weeks, sometimes longer if 



CLINICAL HISTORY OF CHANCROID. 175 

unmolested, the ulcer tends to remain stationary, not undergoing any 
change that can be appreciated. In persons not very susceptible to the 
poison, the stationary period does not exist, but repair sets in after the 
ulcer has reached a certain size. 

Period of Repair. — This comes on gradually. The floor of the ulcer 
grows more pink and even, the edges become sloping, and cicatrization 
advances slowly from the circumference toward the centre. 

Many of the deviations in the typical features of chancroid lead to 
variations in its course. 

Subjective Symptow.s. — An uninflamed, uncomplicated chancroid is 
not painful. If, however, it be irritated by its position, or from local 
applications or other cause, then it becomes more or less painful, accord- 
ing to the amount of inflammation accompanying it. A rapidly spread- 
ing chancroid is painful, as is also a chancroid when attacked by gangrene 
or phagedsena. 

Situatio7i. — Chancroid is commonly found in the furrow behind the 
corona glandis on the penis of the male, and posteriorly in the fourchette 
of the vagina of the female. A natural pocket exists at these points, the 
epithelium is soft there, and abrasions are not uncommon, especially along 
the side of the f renum in the male. In this situation chancroid frequently 
ulcerates its way beneath the frenum, and sometimes perforates the ure- 
thra. The pus naturally gravitates to the fourchette in the female. 

No portion of the body is exempt from inoculation by chancroid. The 
head and face, once considered exempt, have been proved not to be so by 
numerous observers. 

Chancroids are common anywhere upon or within the prepuce in the 
male, the ostium vaginae in the female. At the orifice of the urethra 
they are encountered in both sexes. Chancroid deep in the urethra of 
the male is very rare. The anus and rectum are the seat of chancroid 
either communicated a preposterd venere, or, in the female, due to spon- 
taneous auto-inoculation, the chancroidal pus trickling down over the 
anus from the vaginal fourchette as the patient lies upon her back. The 
fingers of the surgeon or of the patient may become poisoned while 
handling the genitals. 

Number. — Chancroid is generally multiple among hospital and dis- 
pensary patients, often solitary in the better classes, who are more 
scrupulously clean. If multiple abrasions have been simultaneously 
poisoned during sexual intercourse, the resulting ulcers will naturally be 
multiple from the first. Often, however, but one sore comes out at first, 
and this by spontaneous auto-inoculation produces many similar sores in 
the immediate neighborhood. Around the anus, and at the margin of the 
prepuce, it is nearly always multiple. When chancroid is multiple from 
the first, the numerous ulcers are likely to be small. Single chancroid 
is generally larger. 



176 VENEREAL DISEASES. 

Duration, — A typical ordinary chancroid untreated lasts in most indi- 
viduals from four to eight weeks, according to its size. If very small, it 
is likely to get well sooner. The larger it grows the longer time does it 
require for cicatrization. 

Irritated and inflamed chancroids are slow in getting well. To this 
class belong all those about natural orifices and where motion is apt to 
disturb them, the anus, the meatus urinarius, the orifice of the pre- 
puce, and the back of a knuckle. 

Extensive chancroids of the vagina and rectum in the female, and of 
the rectum in the male, sometimes last indefinitely. They cease in the 
end to be true chancroids, and their pus ceases to be auto- or hetero- 
inoculable. Their bases become indurated, they remain in part cica- 
trized, in part ulcerated, and frequently pass for tertiary syphilitic 
ulcerations. Differential diagnosis between them and syphilitic similar 
lesions and some forms of epithelial cancer is sometimes very difficult. 
In the vagina excision is the best treatment. These ulcers are rarely 
encountered except in the wards of a large hospital. They are cus- 
tomarily found upon the persons of old prostitutes. 

The duration of chancroid is greatly influenced by phagedsena. Tour- 
nier has reported a case lasting fourteen years. 

An uncomplicated chancroid occasionally relapses, often without 
obvious cause. It is possible for a chancroid which has almost cicatrized 
to break down again into ulceration and spread possibly to the same 
extent as before, or* even farther. Such a relapse is generally due to 
uncleanliness, careless treatment, sexual intercourse, or abuse of stimu- 
lants. 

An ordinary uncomplicated chancroid may leave no scar. Generally 
the scar is quite visible, especially when occurring upon the outer integu- 
ment, and when once formed it is permanent, generally thin and smooth, 
not pigmented, its size and depth being proportionate to the original sore. 



CHAPTER II. 

CHANCEOID (Continued). 
Diagnosis, Prognosis, and Treatment. 

The differential diagnosis of chancroid lies between syphilitic chancre, 
herpes, balanitis with erosions, ulcerated fissures or abrasions, mucous 
patch, ulcerating gumma, and epithelioma. 

Ulcerated herpes may be mistaken for chancroid, notably when it 
appears as a solitary ulcer. Herpetic vesicles are rarely solitary, and 
when in clusters are apt to run together. When they ulcerate they are 
not so deep as chancroid nor so destructive. A few days' observation 
should determine the diagnosis. 

Balanitis with erosions is not difficult to recognize. When exulcera- 
tions are present they are not undermined and corrugated, but smooth, 
soft, and erythematous. 

Syphilitic chancre is described fully later on. The following short 
diagnostic table (page 178) deals with the important broad typical charac- 
ters of these lesions. Yot closer details of the varied features of syphi- 
litic chancre, the reader is referred to the proper section. 

An abrasion or fissure acquired during sexual intercourse or otherwise, 
ulcerating subsequently, is sometimes suggestive of chancroid. The lapse 
of a short time under the use of a cleansing lotion and dusting powder 
should clear up the diagnosis. The edges of such an abrasion are gen- 
erally jagged, and the base of the ulcer is but little depressed and dis- 
charges a thin sero-pus. But yet such an abrasion by neglect in debilitated 
persons, by lack of cleanliness, by irritating treatment (partial cauteriza- 
tions with nitrate of silver), may acquire in time an appearance so nearly 
resembling that of chancroid that a diagnosis is almost impossible. Under 
these circumstances auto-inoculation may be resorted to after the use of 
cleanliness and local applications have failed to cure. Finally, if the 
patient's state of mmd calls for it, no harm can come by adopting the 
conclusion that the suspicions ulcer may be a source of poison to others, 
and treating it as if it were a chancroid by thorough destructive cauteri- 
zation. 

The diagnosis between chancroid and a secondary syphilitic ulcera- 
tion situated under the prepuce sometimes gives trouble, An ulcerated 
mucous patch rarely exists unaccompanied by other lesions, through aid 
12 



178 



VENEREAL DISEASES. 



of which its nature may be defined, as well as by its own distinctive 
characteristics. 



Syphilitic Chancre. 



Cause. — A specific virus. 



Incubation. — Constant aver- 
age about three weeks. 



Appearance. — R o u n d or 
oval ; flat funnel-stiaped, 
or elevated ; edges adher- 
ent and not undermined ; 
surface smooth and glist- 
ening. 

Secretion. — Scant, serous . . . 

Induration. — Generally 
present ; parchment-like, 
or cartilaginous and ex- 
tensive and terminating 
abruptly. 

Number. — Single generally, 
sometimes multiple. 

Inoculability . — Not a u t o - 
inoculable. 

Course. — Slowly progres- 
sive. 

Duration. — Four to six 
weeks, very slightly 
limited by local treat- 
ment. 

Inguinal Glands. — Multiple 
enlargements, separate 
and freely movable. Sel- 
dom suppurate. 



Chancroid. 



A specific virus 



None in reality ; clinically 
two or three days, or 
longer if the virus be de 
posited on an unbroken 
surface. 

Round, oval, or irregular ; 
ulcerated excavation; 
edges abrupt and under- 
mined ; surface uneven 
and covered with yellow- 
ish membrane 

Free and purulent 



Herpes. 



Absent ; sometimes simu 
lated by inflammatory 
cedema. 



Generally multiple. 



Freely auto-inoculable, re 
producing a typical chan- 
croid. 

Rapidly progressive and 
destructive. 

Four to six weeks, materi- 
ally limited by caustic 
local measures. 

Single enlargement, peri- 
. glandular swelling, tis- 
sues boggy, skin adhe- 
rent, often" suppurate. 



Irritating and acrid dis- 
charges the result of 
uncleanliness or inflam- 
mation. 

None. 



Single round vesicle or 
superficial ulcer ; clusters 
of ruptured vesicles which 
run together and form 
patches of superficial ul- 
cerations with irregularly 
circular borders. 

Slight serous or sero-puru- 
lent (it inflamed j. 

Absent. 



Generally multiple but co- 
alescent. 

Exceptionally auto-inocu- 
lable. 

Slowly progressive. 

Variable; limited by mild 
local measures. 



Mild glandular swellings; 
inflammatory adenitis 
exceptional. 



An ulcerated gumma is quite apt to appear under the corona glandis, 
near the pocket of the frenum, late in syphilis. This ulcer resembles a 
chancroid, and is quite likely to eat into the urethra if not arrested by 
treatment. Its underlying base and border are quite hard, and its his- 
tory shows that it started as an induration under the mucous membrane. 

Certain chancroids are hidden from view. The urethral chancroid 
almost invariably involves the meatus, but possibly might be oat of sight. 
A subpreputial chancroid in case of phimosis, an anal chancroid resem- 
bling fissure — these and possibly other varieties cannot be diagnosticated 
in the usual way. In such case, when the suspicion of chancroid arises, 
the test of auto-inoculation is valuable. If auto-inoculation produces a 
charactey'istic chancroid (especially if the patient be not syphilitic or 



PROGNOSIS AND TREATMENT OF CHANCROID. 179 

cachectic), it may be reasonably predicated that the source of the inocu- 
lated pus was chancroidal. 

Epithelioma should not be confounded with chancroid when carefully 
considered. It occurs as an exuberant new growth, in the form of a 
papillomatous nodule, and not at first as a destructive ulceration. 

In auto-inoculation practised for purposes of diagnosis, the following 
facts should be remembered : 

(1) A gangrenous phagedenic chancroid loses its poisonous quality, 
just as decomposed chancroidal pus is no longer virulent, and auto-inocu- 
lation fails. 

(2) Auto-inoculation of almost any pus may take and produce an 
ulcer somewhat resembling chancroid. 

(3) An ulcer may be a mixed chancre, in which case its auto-inocula- 
tion will take as a true chancroid ; but the patient has syphilis none the 
less. 

(4) Auto-inoculation of an irritated true syphilitic chancre may some- 
times take as an ulcer resembling chancroid. 

(5) A serpiginous phagedenic ulcer is auto-inoculable, but its auto- 
inoculation may produce a chancroid which in its turn becomes phage- 
denic, since phagedsena is a property of the patient and not of the 
chancroidal virus he secretes. 

Prognosis. — -Uncomplicated chancroid gets well in a few weeks, and 
never leads to a result more serious than a trifling local scar. 

The fact that chancroid is not a blood disease and never produces 
syphilis reduces all the damage it can do its bearer to such mischief as 
any ulcer of similar extent and severity might equally well accomplish. 
In rare instances this damage is considerable. A severe and protracted 
chancroid of the rectum leads to stricture of that gut with all its distress- 
ing results ; the mouth of the urethra may be nearly sealed up by the 
contracting cicatrix of a chancroid. 

Phimosis by cicatricial contraction, and deformity by ulceration into 
the urethra, are possible results. 

Erysipelas may attack a simple chancroid as well as any other lesion. 
The more extensive and complicated sores naturally lead to serious local 
consequences. 

Phagedsena may stretch itself over large portions of the surface of the 
body, and last for years. 

Sloughing phagedaena may destroy great segments of the penis, or so 
eat away its outer investment that the resulting scar leaves the organ 
practically useless. A slough has been known to open a large vessel, and 
serious hemorrhage as a complication thus becomes possible. 

These extreme results are indeed possible, but they are so rare that 
they may be disregarded in giving an ordinary prognosis. 

Treatment. — The best preventive treatment against the spread of 



180 VENEREAL DISEASES. 

ulcers upon a patient by spontaneous auto-inoculation is destruction of 
tlie poison at its source, that is to say, cauterization of the chancroid, or 
the most absolute cleanliness if total destruction be impossible. 

Chancroid owes its prolonged existence to its microbic virulence. 
Destroy that virulence thoroughly and the poisonous quality at once dis- 
appears, the ulcer becomes a simple sore, and the process of repair 
begins. 

Unless a chancroid is very young, it is apt to return after being cau- 
terized. It is possible to excise completely a chancroid, including half 
an inch of surrounding tissue, and even though scrupulous care has been 
employed, it may return at the site of the excision. Some old chancroids 
certainly do not get well after the most extensive cauterization. This is 
notoriously true of serpiginous phagedenic sores, but is not the case with 
recent chancroid. Such an ulcer may be cauterized thoroughly and lose 
entirely its chancroidal character. In an old chancroid, however, the 
micro-organisms have infiltrated the tissues for a certain distance beyond 
the base of the ulcer, and cauterization does not reach them. If the 
ulcerated surface is destroyed, it becomes reinfected by poison brought 
from beneath ; and for the same reason when the prepuce is the seat of 
chancroid, the wound of circumcision frequently becomes poisoned, in 
spite of such precautions as burning the chancroid previously to the abla- 
tion of the foreskin and perfect cleanliness during and after the operation. 

That the poison in ordinary cases dies out after a few weeks and is 
eliminated, while in other cases of advancing phagedsena it seems able to 
perpetuate itself almost indefinitely, is largely accounted for by unhy- 
gienic conditions, uncleanliness, and alcoholic excesses. The probability 
is that the diffwence is solely a question of the soil in which the chan- 
croidal poison finds itself, for phagedsena is a quality of the individual 
and does not imply the inoculation of any special virus. 

With the understanding, then, that in many old cases the chancroidal 
poison is widespread, and cannot be all reached by any means capable of 
totally destroying it, it is the opinion among authorities that total destruc- 
tion of the ulcer is the proper course to adopt in all cases in which the chan- 
croid is not of long standing. At exactly what age chancroid ceases to 
be curable by the destruction of its surface, and a reasonable amount of 
tissue beyond, cannot be stated. The rule is to cauterize a chancroid 
thoroughly as soon as its diagnosis is established, and to destroy all points 
of diagnostic auto-inoculation very promptly. Removal of the sore by 
curetting or complete excision is not to be advised at any period. 

Potential caustics are most manageable as destructive agents, and 
therefore better than other means of destruction. The chloride of zinc 
and other pastes are less easy to control than the caustic acids and more 
apt to produce prolonged irritation of the surrounding tissues. Pure 
nitric acid is the best. 



TREATMENT OF CHANCROID. 181 

Cocaine may be used to allay pain caused by the application of the 
caustic acid. 

The use of carbolic and nitric acid in combination is a satisfactory 
method. The carbolic intensifies the local effect of the cocaine and acts 
as an additional analgesic against the stronger acid. 

To prepare a chancroid for cauterization the parts should be first prop- 
erly cleansed and dried. A piece of absorbent cotton moistened with 
four-per-cent solution of cocaine, or a tablet triturate containing gr. ss. 
or gr. i. of the same, may be placed upon the surface of the ulcer and left 
in contact about five minutes. 

Upon the ulcer so prepared a drop of pure carbolic acid is placed ; 
any excess of acid that escapes should be absorbed with a piece of blot- 
ting-paper. After the lapse of a few seconds the surface of the ulcer is 
dried, preferably with a thin strip of blotting-paper. A glass rod, drawn 
to a point, is now dipped into fuming nitric acid, and enough acid placed 
upon the chancroid to fill its depression even with the surface. Any ex- 
cess should be carefully soaked up with blotting-paper. This application 
is entirely painless. The surrounding tissues are held tense, and the 
action of the acid is watched. If the edges of the ulcer are undermined, 
the point of the glass rod should be moved around under the border be- 
neath the surface, so that all the recesses of the sore may be equally 
acted upon by the acid. 

As the acid cauterizes the base of the ulcer, an areola of white color 
is seen to grow gradually around the sore under the epithelium. When 
this areola gets to be as broad as the head of a pin, the cauterization 
should be complete. If it does not become so broad after watching it for 
two or three minutes, the drop of acid should be soaked out of the ulcer 
and a new one put in — and so on until the areola of white, dead, cauterized 
tissue reaches the required thickness. The sore is then dried and the 
subsequent dressing applied. 

The eschar begins shortly to slough off, a line of healthy granulations 
forms around and beneath it. 

A small chancroid thoroughly burned ought to be well in ten days; 
more extensive sores require more time. 

The after-treatment of the cauterized surface should consist of the 
application of a moist dressing, for which purpose corrosive sublimate 
solution, 1 : 4,000, may be employed, keeping the parts thoroughly 
cleansed and the opposing surfaces of the prepuce separated by the inter- 
position of a piece of cotton or lint moistened with the same solution, 
or with 1 : 50 carbolic acid. A dry dressing may be substituted for 
the wet in the form of a dusting-powder, such as iodoform or one of 
its substitutes. The smell of iodoform is a serious objection and cannot 
be satisfactorily disguised. Nosophen is an iodine preparation of strong 
antiseptic action, which has proved of value. Eudoxin is a bismuth salt 



182 VENEREAL DISEASES. 

of nosophen and possesses mild astringent and absorbent properties. 
Other antiseptic powders have also been used, such as aristol, europhen, 
acetanilid, and iodol. 

It is unwise to cauterize a chancroid unless each and every abrasion 
in the neighborhood, and all suppurating spots, can be totally and simul- 
taneously destroyed. For if any chancroidal ulceration remains it is sure 
to poison the healthy ulcer left by the separation of the slough, and to re- 
convert it into a chancroid. Thus, chancroid at the margin of the prepuce 
cannot be cauterized if subpreputial chancroid also exists and is spared. 

In case of numerous subpreputial chancroids, if the foreskin be 
naturally tight the reaction following cauterization may inflame the pre- 
puce sufficiently to cause phimosis and prevent retraction of the foreskin. 
A fear of this occurrence need not deter the surgeon from a use of the 
acid. The cavity of the prepuce can be kept syringed out, and if the 
cauterization has been effective the chancroids will certainly get well, 
even within an inflamed prepuce. 

When all the chancroids cannot be reached, or are so large and old 
that cauterization is not advisable, cleanliness is the first requisite of 
treatment. Frequent washings with sublimate solution 1 : 2, 000 or car- 
bolic 1:40 are to be recommended. The surfaces should then be treated 
either with a moist or dry dressing, which should be changed frequently. 
Unquestionably an efficient local application for such chancroids is iodo- 
form, in powder or mixed into an ointment with vaseline. But respect- 
able people will not use iodoform. Its peculiarly penetrating and 
tenacious odor is unmistakable, Nothing will disguise the odor satisfac- 
torily, although many expedients have been employed for that purpose. 
Solutions of iodoform in ether have been recommended. Their appli- 
cation is painful, the solvent evaporates, and the odor exhales as strongly 
from the fine dust left precipitated over the surface of the ulcer as if it 
had been at first deposited there in its natural state. 

The effect of iodoform upon chancroids is often striking. It freshens 
up the surface and hastens granulation, at which stage it should be dis- 
continued. 

Nosophen also may be employed as a dressing to the chancroids which 
are not treated by cauterization in the same manner as iodoform, after the 
surface has been thoroughly cleansed and dried. This preparation has 
met with decided favor. It contains a large percentage of iodine and is 
inodorous. 

Grlutol or formalin gelatin is an odorless powder which owes its anti- 
septic properties to the fact that when decomposed in contact with a 
wound surface it liberates formaldehyde vapor. Satisfactory results are 
reported from its use in the treatment of chancroid, more particularly 
when all sloughing tissue has been removed and when it is desired to 
assist cicatrization. 



TREATMENT OF CHANCROID- 183 

Tor the relief of the pain, which sometimes is very acute with in- 
flamed chancroids, powdered orthoform may be applied at odd intervals 
between the other applications, and generally with marked effect. 

When the stage of activity of chancroid has passed and the process of 
repair seems to be going on satisfactorily, it is only necessary to apply a 
dry impalpable absorbent powder to allay irritation and prevent friction. 
For this purpose may be used equal parts of bismuth, starch, and oxide 
of zinc, or bismuth and lycopodium. If the ulcers prove sluggish and 
slow to cicatrize in the reparative stage, the application of a solution of 
nitrate of silver, gr. x.-xx. to the ounce, or of the powdered citrate of 
silver (Crede), may hasten their progress toward recovery, or a little 
calomel and bismuth, 1 : 10. Besides these there are many soothing and 
gently stimulating applications. 

If the sores are subpreputial and the prepuce is loose, it is well always 
to pull back the foreskin whatever dressing is employed, and to interpose 
a small piece of gauze or absorbent cotton, in such position that it will lie 
between the sores and the healthy tissues, when the foreskin has been 
replaced. 

When the discharge of pus is considerable, moist dressings are prefer- 
able, and lint slightly moistened with the fluid selected should be kept 
constantly applied to the surface of the ulcer. One of the following 
lotions will serve : 

I^ Hydrargyri bicMor., gr. ss. -ij. 

Aquae, § iv. 

M. 

I^ Acid, carbolic, . . . . . . '. . 3ij. 

Spts. rect., 3 iij. 

Aquae, . § iv. 

M. 

I^ Zinc, suiphocarbolatis, . . . . . .. gr. vi. 

Spts. rect., 3 1]. 

Aquae, § iv. 

M. 

I^ Solut argenti lactas (Crede), . . . . .1 2,000 

With such moist or dry applications and patience, uncomplicated chan- 
croids get well within a reasonable period. 

Internal medication is of no value in ordinary cases. If the patient 
be manifestly debilitated, he should receive tonics and good food, and all 
functional derangements demand appropriate attention, but there is no 
internal specific for chancroid. Eest of body is sometimes desirable. 

Subpreputial chancroid implies a chancroid concealed by the prepuce, 
either congenitally tight so that it cannot be retracted, or in a state of 
temporary phimosis from inflammation. The latter condition will be 
discussed under the head of Complications. 



184 VENEREAL DISEASES. 

When a chancroid is inside of a congenitally contracted foreskin, its 
presence can sometimes only be surmised. Generally a lump, tender on 
pressure, may be detected at one spot, however, or there may be several 
of them ; and the auto-inoculability of the pus, and the possible existence 
of chancroids at the margin of the prepuce, help to make the diagnosis. 

In treating such chancroids, if the prepuce he not inflamed and in 
danger of strangulation^ it is not necessary to use the knife. No exten- 
sive destruction of the parts within the prepuce is apt to occur unaccom- 
panied by such external evidences of destructive inflammation as will 
naturally call for heroic interference. 

Cleanliness is more necessary in treating these chancroids than any 
others. A syringe with a long, flattened nozzle (Fig. 11, p. 36) should 
be used, its point inserted well down to the sulcus behind the corona, and 
into the pockets on either side of the frenum. Warm injections, one of 
the lotions given on p. 183, should be made frequently enough to keep 
the pus from accumulating. Iodoform shaken up with balsam of Peru 
may be injected into the depths of the preputial cavity with the prepu- 
tial syringe. Generally, these chancroids are slow, and cleanliness, with 
time, are the important elements in the cure. 

Chancroids of the margin of the prepuce, there being no ulcers within, 
if they can be thoroughly exposed, should be cauterized. 

Chancroids undermining the frenum, perforating through from one 
side to the other, call for a division of the frenum, to hasten their cure 
and avert the possibility of bleeding, should the frenum become acciden- 
tally ruptured or eaten through by ulceration. This is best accomplished 
by tying a stout silken ligature around it, and cutting the ligature short. 
The ligature cuts its own way through very promptly, and then the open 
chancroid may be treated more satisfactorily. If chancroid in this region 
is not controlled it may give great annoyance, its destructive action ex- 
tending into the median fossa of the glans, or perhaps perforating the 
urethra, producing urinary fistula. 

Chancroids at the margin of the meatus urinarius may be cauterized 
unless they run too far down into the urethra. In the latter case iodo- 
form plugs (a roll of lint covered with cerate and sprinkled with iodoform) 
will hasten recovery. Urethral chancroids lower down than the fossa 
navicularis are excessively rare and some of the cases reported are errors 
of diagnosis. 

Anal and rectal chancroids are always obstinate and difiicult to man- 
age. The daily stretching of the parts by the faeces and the difficulty 
of maintaining perfect cleanliness are the main obstacles to recovery. 

Cauterization is inappropriate for ulcers in this region. Frequent 
washings with warm water containing corrosive sublimate, and confine- 
ment to bed, with lavish use of iodoform powder upon all the ulcerated 
surfaces, is the best treatment for recent chancroids in these regions. 



TREATMENT OF CHANCROID. 185 

Constipation must be prevented. When the chancroid has lasted for 
years, and produced stricture of the rectum, extirpation with the knife 
or linear resection may be required. 

ChoMcroid of the Fingers. — When the surgeon or accoucheur gets 
chancroid upon the finger, it should be thoroughly cauterized, and 
dressed with one of the moist or dry applications given above. The 
finger should be kept immovable upon a splint. A chancroid on a 
knuckle is sometimes as hard to cure as a chancroid of the anus or at the 
meatus urinarius, the reason being that the incessant injury done by 
motion of the part keeps the ulcer alive. An ordinary abrasion will 
sometimes ulcerate and last for weeks upon a knuckle, and be mistaken 
for a more serious condition. 



CHAPTER III. 

THE COMPLICATIONS OF CHANCROID. 

An ulcer doubtless cannot exist without some inflammation, but a 
typical chancroid is attended by very little. Most chancroids, however, 
as encountered clinically, are inflamed in a measure, and possess all the 
qualities of inflammation to a greater or less extent. This amount of 
inflammation does not constitute a complication. 

When a chancroid inflames from mechanical or chemical irritation, or 
on account of the neglect of the patient, its base hardens, its discharge 
grows thinner and sanious, pain is complained of, and generally the 
course of the sore is prolonged, the surrounding tissues becoming oedema- 
tous and indurated, and the ulcer finally pale, flabby, unhealthy, going 
on to a slow cicatrization. Simple bubo is very much more apt to occur 
with an inflamed chancroid than with a typical ulcer. 

When inflammation complicates subpreputial chancroid, the tissues of 
the prepuce become much engorged, and sometimes very hard and rigid 
from stiffening of the connective tissue by inflammatory exudation. A 
superficial lymphangitis is the cause of these phenomena; the larger 
lymphatic vessels may escape entirely. This lymphangitis is not an 
uncommon complication of chancroid. 

Inflammatory 2^^^'^^osis or paraphimosis, under these circumstances, 
often ensue. If the chancroid occupies the inner surface of the prepuce, 
the latter is in danger of strangulation and may undergo total gangrene, 
a large portion of the prepuce, with the chancroid, sloughing away and 
allowing the glans penis to protrude through the opening, making a sort 
of double-headed penis. The remains of the prepuce in such cases con- 
tinue thickened and indurated, and require to be trimmed away finally, 
when cicatrization is complete. 

A more disastrous result of inflammatory phimosis is the possibility 
of many new points of auto-inoculation within the cavity of the prepuce, 
the retained poisonous pus excoriating the surface of the glans penis and 
perhaps inoculating the meatus. Portions of the new chancroids may 
then slough, and considerable loss of the glans penis ensue, with stricture 
of the meatus from cicatrization. The liability of causing bubo by allow- 
ing an inflamed prepuce over a chancroid to remain long unrelieved is to 
be borne in mind, and the possibility of extensive denudation of the penis 
by the backward burrowing of the retained chancroidal pus lias been 
clinically proved (Vidal). 



THE COMPLICATIONS OF CHANCROID. 187 

Inflammatory paraphimosis may complicate a chancroid when the 
prepuce is short. The swelling encircling the penis may become so great 
that the circulation of that portion of the penis lying in front of the 
constriction is menaced. 

The treatment of the inflammatory complications of chancroid is ob- 
vious. Eest must be insisted upon, the penis elevated and covered with 
moist, cooling, evaporating lotions, or with astringent solutions. One of 
the following should be kept constantly applied cold upon a thin cloth on 
the outside of the penis : 

I^ Glycerini, . . . . . . . . . fTi xx. 

Spts. rect., . . . . . , , . .3 i.-ij- 

Liquor, plumbi subacetat. diL, . . . q.s. ad § i. 
M. 
Or— 

Aluminum Acetate Solution. 

^ Aluminis, ... . . - • . gr. xxx. 

Plumbi acetat., ^ .... - . 3 iiss. 

Aquae, . § vi. 

M. Filter. 

These applications are palliative. The treatment of the chancroid 
meantime goes on by subpreputial injections, iodoform applications, or 
whatsoever it may be. If the subpreputial discharge of pus gains in 
quantity, if the inflammation fails to yield and gangrene is to be feared, 
then but one course is left, namely, to slit open the cavity of the prepuce 
and dress with iodoform or nosophen ; or, better still, antinosine, which 
is the sodium salt of nosophen, and especially lauded for sluggish ulcera- 
tions. This last application is generally employed in a five- to eight-per- 
cent solution with glycerin or water. Cauterization in these cases will 
not prevent the wound from becoming inoculated and only prolongs the 
duration of the sore. 

In cases of paraphimosis the line of stricture of the prepuce must be 
divided with the knife as soon as the circulation of the penis in front of 
it is threatened. If the circulation continues perfect it is better in most 
cases not to attempt to reduce the paraphimosis, since the latter insures 
the advantage of leaving the ulcers exposed to view. 

Phagedenic Chancroid. — This is the most formidable of all the local 
complications. Phagedsena occurs in two forms : sloughing or gangren- 
ous phagedsena and serpiginous. The predisposing general causes of 
phagedaena are not uniform. It sometimes attacks a florid, healthy-look- 
ing youth, and often spares a cadaverous consumptive or a patient debili- 
tated by excesses of all sorts. It is a rare complication. Phagedsena is 
not confined to chancroids. Any ulcer — syphilitic or simple — may be 
attacked by it. It is a peculiar quality of the individual. The pus from 
a phagedenic ulcer will not produce phagedaena by hetero-inoculation. 



188 VENEREAL DISEASES. 

This has been abundantly proved by Fournier, Sperino, Eollet, and 
others. Conversely, it is known that a simple chancroid produced upon 
a patient with phagedsena is liable also to become phagedenic, showing 
clearly that the phagedenic quality is a personal one. 

Among the presumed predisposing causes of phagedsena have been 
grouped all depressing dietetic, hygienic, diathetic, and pathological con- 
ditions — old age, misery, alcoholism, scrofula, malaria, digestive troubles 
— but not one of these causes can be proved sufficient in the majority of 
cases. As local causes, lack of cleanliness, neglect of treatment, and im- 
proper treatment, have been accredited with a fair share of the blame in 
its production. It is probable that phagedsena is a personal idiosyn- 
crasy, not existing continuously in a given patient, and aggravated by 
those causes which have generally been considered capable of generat- 
ing it. 

When a chancroid is attacked by gangrenous phagedsena the tissues 
beneath it swell up and become livid for a distance around. The pus 
gets scanty and sanious. The ulcer grows larger and dryer ; a slough, 
gray, brown, black, promptly forms upon it ; the part becomes excessively 
painful ; the slough separates promptly or slowly, according to its thick- 
ness ; and then comes a lull in the process. 

After a rest of longer or shorter duration a new attack of pain an- 
nounces the commencing formation of a new slough, and the process 
repeats itself. Large excavations in the tissues are thus caused, for 
sloughing phagedaena spares nothing. It does not dissect out the vessels 
or arrest itself at a barrier formed by a new tissue. It may sweep away 
the penis in the male, destroy the labia and perineum in the female, make 
the most extensive ravages before its fury is appeased. It may even 
endanger life by exciting peritonitis when ulcerating deeply over the 
abdomen, or by giving rise to profuse hemorrhage by cutting through a 
blood-vessel. It may wear out the sufferer by pain, and all the symp- 
toms of general septicaemia, fever, exhausting diarrhoea, and debilitating 
sweats. 

The poisonous chancroidal quality of these ulcers remains, as has been 
tested by inoculation ; yet a part of the poisoned surface seems to grow 
tolerant of the virus after a time. 

Serpiginous phagedaena is milder in all respects than the sloughing 
variety, but is more chronic. The former exhausts itself, yields to treat- 
ment, or kills the patient within a reasonable period, while creeping 
phagedaena seems to have little or no reaction upon the general health, is 
not attended by much pain or any fever, and yet continues sometimes 
almost indefinitely. A phagedenic chancroid of fourteen years' duration 
was reported by Fournier. 

Serpiginous phagedaena commences as a swelling at the borders of the 
chancroid, which appear more red than usual, and as the connective tissue 



THE COMPLICATIONS OF CHANCROID. 189 

is destroyed by gangrene, the borders of the ulcer become largely under- 
mined. The remaining bridges and their flaps of livid skin, perforated 
here and there where the ulcerative action has eaten through to the sur- 
face, make pockets and sinuses around the ulcer, some of which extend 
long distances. In this manner all the integument of the penis may be 
dissected up, large pouches run down the thigh and around the crest of 
the ilium, or (more rarely) up over the abdomen. 

As one side of the ulcer advances the other generally heals, and thus 
the ulcer creeps for months, perhaps for years, over the surface. The 
base of the sore retains its chancroidal appearance. It is uneven, gray, 
covered with adherent, pultaceous secretions, and occasional prominent, 
flabby granulations bleeding at the slightest touch. The discharge is 
watery, bloody, usally free, occasionally scanty. 

Periods of rest of greater or less length occur during the progress of 
phagedaena, when the ulcer remains stationary, or even, perhaps, seems 
to be healing all around; and then, without apparent cause, the phage- 
denic action will commence again at one border, while cicatrization goes 
slowly on undisturbed at the other. Phagedaena once seen cannot after- 
ward be confounded with anything else. 

The bubo attending phagedenic chancroid may be a simple one or 
may be virulent^ and itself take on phagedenic action. Phagedaena 
seldom attacks simple inflammatory bubo. 

Treatment. — All possible improvement in the hygienic surroundings of 
a patient, a generous and varied diet, and internal tonic measures are of 
value in treating phagedaena. Cod-liver oil, if it can be digested, quinine 
in large doses, especially in the depressing fever of sloughing phagedaena, 
and iron, are suitable remedies. Custom has sanctioned the preference 
for Eicord's tartrate of iron and potassium, in gr. x.-xx. doses in solution, 
as a tonic. Eicord thought it was nearly a specific, and some cases cer- 
tainly do well upon it. The pain if great is to be relieved by opium. 

The local treatment is more important than the general, and both 
forms of phagedaena require the same local measures. Total destruction 
of all the tissues involved, and extending widely beyond the immediate 
area of disease, is certainly the best treatment. This cauterization must 
be a severe one. It will not destroy more tissue than the ulcer left to 
itself would have eaten away, and an imperfect cauterization will do more 
harm than good. 

The ulcer must first be made ready for cauterization. Anaesthesia 
may be obtained by infiltrating the surrounding tissues with cocaine (four 
per cent) or eucaine. All overhanging bridges and flaps of undermined 
livid integument must be cut away. It is best to do this with scissors, 
and to sear the bleeding edges at once with a Paquelin cautery. When 
all sinuses have been laid open, and the whole ulcer is flat and exposed 
and the bleeding arrested, then the surface should be washed with a solu- 



190 VENEREAL DISEASES. 

tion of corrosive sublimate 1 ; 2, 000, or two-per-cent solution of carbolic 
acid, and dried with blotting-paper. Next, it should be touched all over 
with pure carbolic acid and dried. 

Nitric acid cannot be depended upon for final cauterization. A cer- 
tain depth beneath the ulcer must be destroyed in all directions, in order 
that it may prove effective. A liquid caustic cannot be applied uniformly 
over the whole surface ; it will spare the elevations, and spend its force 
upon the depressions. On this account other caustics are better. 

The choice lies between the actual cautery and a caustic paste. The 
galvano-cautery or Paquelin cautery may be used and should be em- 
ployed with the utmost deliberation and care, so that the entire base and 
surrounding integument for one-fourth of an inch is absolutely charred, 
and thus a cure of the phagedsena may be confidently expected. 

Unfortunately, but few phagedenic sores are sufficiently small, or so 
situated as to be certainly totally destroyed in this manner without endan- 
gering surrounding parts. In such case, if the ulcer is suitable for cau- 
terization at all, a caustic paste should be employed. Either the chloride 
of zinc or the carbo-sulphuric paste may be used — preferably the former, 
freshly made, by mixing equal parts of chloride of zinc and dried flour 
with a few drops of alcohol to the consistency of a paste. This is to be 
packed and crowded into all the uneven crevices and irregularities of the 
surface already prepared, as directed above, and thoroughly dried out. 
The packing is done with a small wooden spatula, and the excavation of 
the ulcer filled in even with the surface of the surrounding integument at 
the edges, but not laid on thicker at any one spot than one-eighth of an 
inch, since this thickness is ample. The packing is covered with a piece 
of absorbent gauze or lint cut to fit, the surrounding epidermis is greased 
with vaseline freely, then the whole surface is generously dusted with 
powdered starch or lycopodium, covered with a thick layer of absorbent 
cotton, the whole retained by a snug roller bandage. 

Morphine may be required to control pain. The bandages should be 
removed in from twelve to twenty-four hours, the surface washed and 
dried with absorbent cotton, and finally dressed with a mildly carbolized 
wet dressing, or any other simple application. 

Bromine solution, 1 : 3, has been suggested for these ulcers, and a 
saturated solution of antinosine — the sodium salt of nosophen — but 
neither of these means has been generally enough emploj^ed to justify a 
conclusion as to its exact value. The methods above detailed are cer- 
tainly efficient when cauterization is justifiable. 

There are many cases of bad phagedsena in which cauterization should 
not be attempted. In any case, when the whole surface cannot be laid 
bare and included in one cauterization, other means must be used. This 
exception covers many cases of vaginal and rectal phagedaena — cases in 
which extensive layers of integument have been dissected up, and cases 



THE COMPLICATIONS OF CHANCROID. 191 

in which long sinuses exist involving too extensive destruction of tissue. 
Cauterization is not applicable when there is danger that the caustic 
may do harm by eating in too deeply, as over the sheath of the femoral 
vessels. Finally, if thorough cauterization has once failed, it is better 
to try other means before resorting to it again, and under these circum- 
stances the occasional application of the lighter caustics, pure carbolic 
acid, or bromine 1 : 3 in glycerin, may freshen up the surface and help 
to cure in many cases in which thorough cauterization cannot be applied 
or has failed. 

When cauterization is not desirable, powdered iodoform was formerly 
considered the best local application; antinosine, in powder form or a 
saturated solution as a wet dressing, is also to be recommended. The 
powder or solution should be freely applied to the ulcer and should be 
renewed as often as the discharge collects, which, together with disin- 
fecting washes of carbolic acid or weak chlorinated soda water, is an 
excellent resource, and often acts favorably. 

The method of treating phagedenic, syphilitic, and other unhealthy 
sores, by intermittent or continuous submersion in water, has been followed 
by some exceptionally good results. 

The names of Hebra in Germany, Hutchinson in England, and Hem- 
ard in France are well known in connection with this treatment. We 
have seen the most salutary results from this method in very unpromis- 
ing cases. The reliable results which have been published certainly 
render it worthy of trial in severe cases of phagedsena, whether attacking 
chancroid, chancroidal bubo, or a syphilitic sore. 

The method of submersion as employed by Mr. Cooper' is simple and 
easy to carry out, while its effectiveness can hardly be doubted after 
reading the report of cases in which it was used. 

The patient is made to sit in a hip-bath, or other convenient bath, so 
that the site of the ulcer may be entirely submerged for from eight to ten 
hours a day. The water is kept as nearly as possible at a uniform tem- 
perature of 98° F. Here the patient quietly remains all day. In the 
evening finely powered iodoform or other suitable dressing is put upon 
the sore. 

On the following morning the patient enters his bath without disturb- 
ing the dressing of his local ulcer. The water of the bath thoroughly 
soaks these dressings and removes them without pain. 

A purge before the course of baths, tonics, and any other appropriate 
internal medication during their use, are recommended. 

Some excellent cases are detailed, showing the rapidly favorable 
influence of the submersion in from two to thirteen days. 

The application of hot water at as high temperature as can be toler- 



1 London Lancet, May 24th, 1879, p. 731. 



192 VENEREAL DISEASES. 

ated has also been employed as a therapeutic agent in the treatment of 
chancroid, and it is claimed with excellent results. 

Chancroid is not said to be complicated by syphilis when a patient 
with syphilis gets chancroid. The term is applied only to the " mixed 
chancre, " when both poisons exist at one and the same time in the local 
sore (p. 212) . The previous existence of syphilis in a patient does not 
at all modify the appearance or course of chancroid. 

Lymphangitis and Bubo. 

Lymphangitis. — Chancroidal Ij^mphangitis is not a frequent complica- 
tion. The lymphatic trunks rarely become implicated without simulta- 
neous bubo, while bubo frequently occurs when there is no lymphangitis. 

Lymphangitis attending chancroid is of two varieties : inflammatory 
and virulent. 

Inflammatory lymphangitis attacks one or more of the lymphatic 
trunks upon the back or sides of the penis which become thickened, 
mainly by inflammation of the connective tissue surrounding the vessel. 
A hard cord is felt under the skin, with perhaps several knotty swellings 
along its course, usually sensitive to pressure, sometimes adherent to the 
skin, varying in size from a goose-quill to a broad band, according to the 
extent of the surrounding inflammation, sometimes marked upon the sur- 
face by a red line. This hard cord may extend from the chancroid a 
certain distance, or may be traced to the root of the penis. Sometimes 
it is found only toward the root of the penis, being absent in front. If 
the superficial lymphatics are also involved, the skin may become oedema- 
tous, hot, and painful. If the inflammatory symptoms run high, there 
IS a corresponding amount of general reaction in the way of fever, etc. 

The terminations of inflammatory lymphangitis are by resolution and 
suppuration. The pus in the latter case is always simple, non-virulent, 
and is due to excess of inflammatory action. The abscess generally heals 
promptly, and the lymphangitis always gets well. 

Virulent lymphangitis is very rare. . It possesses all the foregoing 
symptoms in a high degree, and goes on promptly and necessarily to sup- 
puration at one or more of the knotty points along the inflamed cord. 
The pus discharged is auto-inoculable and yields chancroid. The ab- 
scesses at the suppurating points do not heal, but become chancroids, and 
require to be treated as chancroids. 

Treatment. — Mild cases require no special care. If pain and surface 
redness run high, a cool astringent or evaporating lotion is appropriate. 
The aluminum acetate mixture (see p. 187) is a favorite application, to 
be used in the form of a wet dressing. The patient should remain in 
bed with the penis elevated, and not hanging down between the thighs. 
Poultices are objectionable, since they soften the epidermis and tend to 



THE COMPLICATIONS OP CHANCROID. 193 

increase the size of the resulting chancroid, should suppuration ensue and 
prove virulent. Abscesses should be opened promptly, and the dressing 
frequently changed. They get well shortly under wet or dry antiseptic 
dressing if the suppuration be simple ; if virulent they are chancroids, 
and must be treated as such. 

Bubo. — ^The term " bubo, " although generally confined to inflammatory 
enlargement of the inguinal or crural glands, may be correctly applied to 
a similar condition in any lymphatic gland in connection with a venereal 
ulcer. 

Taking the statistics of various writers, the frequency of bubo as a 
complication of chancroid is between nineteen and thirty-three per cent. 
The inflammation is confined to the ganglia of the superficial chain ; the 
glands nearest the ulcer lying below Poupart's ligament, above the 
saphenous opening, are most often involved. 

Bubo usually occurs in the groin corresponding to the side of the 
penis involved by the chancroid — but it may be in the opposite groin; or 
double bubo may occur with a single sore, when the latter is located in 
the region of the frenum. 

Cause. — It is generally held that neglect of treatment and uncleanli- 
ness are exciting causes in the production of bubo. The irritation at- 
tendant upon balano-posthitis with phimosis, specific and non-specific 
urethritis may be sufficient to produce inflammatory enlargement of the 
inguinal or crural glands of a mild degree, the latter conditions as well 
as ulcerated herpes and severe balano-posthitis may be productive of irri- 
tations of such an intense character as to result in suppurative bubo, 
especially in those of debilitated condition and lymphatic habit. Ducrey 
claims that the streptobacillus which bears his name is found in the pus 
of chancroidal bubo, and in this contention he is sustained by those 
workers who confirm his views regarding the specific character of this 
organism. Among these are Welander, ' Krefting, ^ and Unna.^ 

Deutsch * found the Krefting-Ducrey bacillus in the pus of three cases 
of bubo, inoculations from which produced typical chancroid. In thirty- 
four cases of bubo examined by him in which the bacillus was not found 
inoculation was not successful. 

In many cases of bubo the ordinary pus organisms are demonstrated, 
and in some cases the pus is found to be free from pyogenic microbes. 
Many authors maintain that the ordinary pus organisms and not a specific 
microbe are the direct cause of buboes ; others that they are due to the 
poison generated by pyogenic micro-organisms. In view of the bacterio- 
logical observations made by Deutsch and others it is likely that the con- 

^ Archiv fiir Dermatol, und Syph., 1892. 

2 Ibid. 

3 Monatschrift fiir prakt. Dermatol., 1892, vol. xiv. et al. 

^ Centralblatt ftir die Krank der Harn- und Sexual-Org. , 1897, pp. 354 and 424 

13 



194 VENEREAL DISEASES. 

elusions of all of these authors are more or less correct, and that some 
baboes are caused by the presence of ordinary pus organisms, others by 
the absorption of the chemical products or toxins of these bacteria, while 
a few are due to the presence of the specific organism of chancroidal 
virus resulting in the production of the so-called virulent buho. It is 
again claimed by some that this last form is not due to the propagation 
of the chancroidal virus through the lymphatics, but that inoculation 
takes place after the bubo has been opened. While this may be the case 
in some or even a majority of instances, it certainly is not invariably true. 

There are two distinct types of bubo — simple and virulent. A simple 
bubo is that form which occurs in connection with the irritation propa- 
gated along the lymphatic radicals in connection with balanitis, herpes, 
gonorrhoea, an irritated syphilitic chancre or chancroid. A sore of any 
kind may give rise to it in a subject who is predisposed by being run 
down physically. Chancroid is the most common cause. 

A virulent bubo may arise from a simple inflammation or phagedenic 
chancroid, and is so called because it takes on the character of chancroidal 
ulceration ; and assuming its cause to be the specific organism of this 
venereal sore, it must be derived either by propagation through the lym- 
phatic channels or by inoculation after the bubo has been opened. 

Simple buho generally occurs early, if at all (in connection with chan- 
croid), commencing within a week or two after the sore is fairly under 
way ; yet it may occur when the ulcer has nearly run its course. The 
immediate determining causes are often fatigue, excess, mechanical injury 
to the gland ; but chancroid alone may cause it without the assistance of 
any of these additional provocations. 

Generally only one gland is affected, or one gland so much more 
prominently than the others that the latter may be disregarded. 

The symptoms of simple inflammation of a lymphatic gland are at first 
a sense of stiffness in the groin and a slight swelling of a single gland. 
The gland rolls under the skin, is sensitive to pressure, and the seat of 
pain upon standing, walking, and particularly upon going upstairs. As 
the gland increases in size, the pain proportionately increases. The skin 
finally adheres and becomes reddened; then it becomes cedematous, and 
a central soft spot appears, indicating suppuration. Occasionally the 
periglandular tissue suppurates, the gland itself undergoing resolution. 
Left to itself, the abscess opens, discharges for a varying period, accord- 
ing to the general health of the patient and the condition of the sore. 
Much exercise always interferes with rapid repair,. Occasionally the pus 
burrows in various directions beneath the skin. 

This is the typical inflammatory bubo, whether it occurs during the 
course of chancroid, urethritis, etc., oris of idiopathic origin. Its course 
may be arrested spontaneously, or by treatment at any period, even after 
suppuration has been established. The amount of fever or general sys- 



THE COMPLICATIONS OF CHANCROID. 195 

temic disturbance is considerable in some cases, absent in others. Sup- 
puration may be announced by chill. Finally, simple bubo may be com- 
plicated by gangrene or erysipelas. 

Another form of bubo, which is known as indolent or strumous bubo, 
occurs generally in those suffering from malnutrition or a debilitated 
constitution. This bubo is often double, a number of lymphatic glands 
being involved on each side. The tumor may reach the size of an egg or 
a small orange, be attended by but little pain, and perhaps no appreciable 
systemic disturbance. The adherent integument over the lump is thin, 
livid, sometimes shining, usually of a dead hue, sometimes smooth, 
sometimes irregular, oedematous, and undermined. 

This livid, chronic enlargement in the groin may continue for weeks, 
possibly for months unchanged, occasioning very little annoyance. 
Sometimes, on the other hand, it is attended by considerable pain. A 
chancroid may have healed up long before any change has occurred in the 
buboes — sometimes even before they have reached their full development. 

The pus may burrow in different directions slowly under the skin, 
and at the bottom of long sinuses other little livid abscesses may form 
and open spontaneously, leaving rigid fistulse to discharge indefinitely. 

A spontaneous or simple bubo arising from a strain, fatigue, or local 
injury in a strumous or cachectic person has nothing to do with syphilis 
and no connection with chancroid, and does not imply either of the latter 
diseases any more than does a suppurating gland in the neck. Much was 
formerly written of this buhon d^emhUe. Its claims to recognition as a 
venereal malady have been entirely overthrown, and its accidental posi- 
tion in the groin alone gives it interest and prominence, more than at- 
taches to the same identical lesion when it occurs spontaneously in the 
axilla. 

Virulent huho may arise from a simple, from inflamed, or from a 
phagedenic chancroid. There is no certain date of its appearance. It 
may commence very late. Occasionally it declares itself just as the 
simple chancroid from which it arises is getting well. Sometimes double 
bubo exists with a single chancroid — on one side a simple bubo, on the 
other a virulent. 

The first features of virulent bubo are those of simple suppurating 
adenitis accentuated. When the abscess ruptures or is opened with the 
knife its true chancroidal character begins to appear. The opening be- 
comes larger by the slowly advancing ulceration. The borders get hard, 
livid, undermined, while the integument surrounding the edges assumes 
a dusky purple hue, perhaps is perforated in a new spot, or sloughs away 
in pieces. The bottom of the abscess, now an ulcer, becomes irregular, 
worm-eaten, covered with a pultaceous, adherent deposit, discharging 
plentifully a purulent secretion, which is inoculable upon the bearer. 

This ulcer, with its ragged, abrupt, ulcerated, and undermined edges, 



196 VENEREAL DISEASES. 

its uneven, pultaceous floor, and auto-inoculable discharge, is a true chan- 
croid. The pus may burrow along the groin, down the thigh, or upon 
the abdomen. 

Phagedsena, either in the sloughing or in the serpiginous form, may 
attack a chancroidal bubo. The latter is more common, and usually the 
origin of those extensive chancroids which last for so many years. 

A phagedenic bubo may have originated from a non-phagedenic chan- 
croid, just as a phagedenic chancroid of the penis may have a simple bubo 
or no bubo at all. 

Treatment. — Simple bubo sometimes may be aborted. The moment 
a trifling stiffness in the groin begins to be felt, and a single gland is 
found, by pressure, to be the sensitive spot, the greatest amount of rest 
possible should be insisted upon. The diet should be moderated in con- 
formity to the rest enjoined. Stimulants should be avoided. A laxative 
may be required. The chancroid should be cauterized at once, if it be a 
sore suitable for that treatment. 

Iodine does not seem to possess any value in aborting simple bubo, 
and most ointments which have to be rubbed in with the fingers lead to 
as much harm by mechanical irritation as they do good by virtue of the 
medicament they contain. Belladonna ointment in conjunction with the 
application of a snug spica bandage is said to yield good results in some 
cases. 

Cold applications are useless. The hypodermic injection of carbolic- 
acid solutions, from gr. viii.-x. to the ounce, and of one-per-cent solution 
of benzoate of mercury have been advocated, the former by M. K. Taylor, ' 
the latter by Welander, ^ who report successful results by the use of these 
interstitial injections. These methods lack general indorsement. 

When abortive measures have proven unsuccessful or when abscess of 
the gland forms promptly, in spite of efforts to arrest it, flaxseed poul- 
tices may be employed to encourage suppuration. At this stage drainage 
is obtained by simple incision, or total extirpation of the hyperplastic 
glandular structures is effected by curetting. 

After evacuation of the abscess the resulting cavity is treated as an 
ordinary suppurating wound with antiseptic lotions, such as corrosive 
sublimate 1:2,000, or carbolic acid 1:50, being dressed daily, carefully 
packed with absorbent gauze, and granulation encouraged by the aid of 
balsam of Peru or other stimulating applications. A five-per-cent mix- 
ture of the balsam and castor oil is useful here, as it is in other granulat- 
ing wounds. 

Hadyen^ advocates the use of ten-per-cent iodoform ointment in the 

^ American Journal of the Medical Sciences, April, 1882. 

'^ Archiv fiir Dermatol, und Syph., 1892. 

3 Chicago Medical Journal and Examiner, September, 1886. 



THE COMPLICATIONS OF CHANCROID. 197 

abscess cavity after it has been irrigated and cleansed with peroxide of 
hydrogen and bichloride of mercury. His report of cases gives an aver- 
age duration of eighteen days. 

Another method, advocated by Howland, of Washington, substitutes 
for iodoform vaseline the preparation known as glutol-Schleich or forma- 
lin gelatin. This author packs the abscess cavity with the above prepara- 
tion, which is left in situ without redressing for six days. He reports an 
average duration of eleven days, the shortest being six and the longest 
eighteen days. 

Complete extirpation of buboes has been advocated by several writers. 
Howland ^ adopted this method in four cases in which it required from 
two to twenty-eight days to effect a cure. It is obvious that in most 
cases of simple bubo this method has nothing to recommend it in prefer- 
ence to other less radical procedures. This does not apply, however, to 
the treatment of the indolent or strumous bubo. In such cases much 
valuable time may be gained to the patient, together with improvement 
in the general health, by complete extirpation of the diseased glands. A 
general anaesthetic should be administered, all pockets and sinuses laid 
freely open, and the diseased and infiltrated tissues dissected out or 
scraped with a sharp curette. All the exposed glands, whether they be 
apparently healthy or not, should be removed, which may necessitate 
careful dissection, sometimes as deep as the sheath of the femoral vessels 
or even between them. The hemorrhage is sometimes quite profuse, but 
is readily arrested by the application of ligatures and subsequent packing 
of the wound. The after-treatment of the resultant cavity is the same* 
as that following the incision of simple bubo. The local treatment o:" 
the indolent form of bubo should be supplemented by proper internal 
remedies in the form of tonics, a generous diet, and cod -liver oil. 

The treatment of virulent bubo is that suitable for a large chancroid. 
Surgical cleanliness is of the first importance. Cauterization is generally 
not desirable. The entire surface and abscess cavity should be copiously 
irrigated with strong antiseptic solutions. Any undermining of the 
borders or tendency to burrow should be met with a prompt incision to 
the bottom of the pouch. The cut edges may become ulcerated and the 
chancroid enlarged, but this is preferable to the formation of a sinus. 
The bottom of the ulcer should be more thoroughly cleansed by curetting 
and removal of all dead tissues and sloughing detritus. Having exposed 
the entire surface to the free access of local remedies, subsequent treat- 
ment and management are the same as for ordinary chancroid. 

^ "The Cause and Treatment of Bubo," Medical News, November 26tb, 1898, 



CHAPTER IV. 

SYPHILIS. 
Definition — Origin — Course — General Pathology. 

Definition. — Syphilis is a specific constitutional disease, acquired either 
by inheritance or by contagion — generally but not always during sexual 
intercourse. It is characterized by the appearance of a primary lesion at 
the seat of inoculation, followed by periods of eruption, varying in nature, 
severity, and duration. The earlier symptoms are superficial, the latest 
involve the deeper structures. No organ in the body is exempt; the 
connective tissue is most constantly affected, at first in the form of a low 
chronic inflammation, and later as the seat of small morbid growths 
known as gummata. Treatment may shorten and modify the disease; 
time alone can wear it out. A perfect recovery is possible. 

The origin of syphilis is involved in impenetrable darkness. It has 
been the subject of learned essays and volumes. Dr. Buret in a literary 
exposition' upon the subject affirms that it was known among the Chinese 
two thousand years before Christ, and many believe that it has existed 
in all countries ever since ; that it was known to physicians of ancient 
days and during the Middle Ages, although its nature was not then fully 
recognized. Other investigators aver as emphatically in learned writings, 
equally founded upon fact, that the disease was brought from America 
upon the ships of Columbus, and from this origin spread like a plague 
through all Europe. 

It is not within the scope of this work, which proposes to deal with 
practical questions, to enter into an analysis of the various views ex- 
pressed regarding the primeval origin of syphilis. 

It is well, however, to know that it was not recognized as a morbid 
entity until the end of the fifteenth century, at and after the period of 
the siege of Naples (1494-95) by Charles VIII. ; that then, and for a 
considerable time thereafter, the disease behaved with unwonted viru- 
lence, attacking all classes of society, and killing a large number of its 
victims. From that time to the present day syphilis has been a subject 
of peculiar interest to all classes of medical men. It enters the domain 
of every branch of pathology. 

Whatever and wherever was the first origin of syphilis matters little ; 

^ "La Syphilis aujourd'hui et chez les Anciens," Paris, 1890. 



SYPHILIS. 199 

now it is everywhere, and probably spreading. All countries on the 
globe possess it. 

In certain parts of the world syphilis is said to be exceptionally mild, 
as in Portugal. This has been ascribed to the fact that the population 
are saturated with syphilis, and owe their immunity to their syphilitic 
forefathers. In certain countries, on the other hand, syphilis is said to 
be exceptionally malignant — South Sea Islands, Mexico. The acquisition 
of syphilis by one race of people from another is believed to produce a 
severe type of disease. It is well known that sailors habitually have the 
disease severely, and they acquire it doubtless often in foreign ports. 

A natural deduction from these facts is, that finally syphilis will 
become uniformly acclimated all over the world; that it will diminish in 
severity as it increases in extent, and perhaps at last may exhaust its 
virulence entirely. Certain it is that the syphilis of the present day is 
not the syphilis we read of in the past. Occasional cases of malignant 
syphilis and bad types of disease still appear to remind us of what the 
poison can do, and the damaging blight which the inherited taint often 
inflicts upon its innocent victim attests the continued virulence of the 
malady. In a majority of cases, however, in reasonably healthy persons, 
the type of the disease, as encountered at the present day, is mild ; it 
can be controlled to a great extent by treatment. Thousands of individuals 
pass through it unharmed in tissue, in feature, in function, to reach a 
green old age and die of natural causes, leaving behind them healthy 
offspring. 

Course. — After contact of the poison with a surface capable of absorp- 
tion, nothing unusual happens for several weeks ; this is the period of 
incubation. 

The lesion which first appears at the inoculated point is called a 
chancre, whether it appears upon the genitals, the fingers, the face, or 
elsewhere — whether it is a dry papule, a moist tubercle, or an excavated 
ulcer. Within two weeks of its appearance the neighboring lymphatic 
glands generally become slightly enlarged and very hard, in an almost 
painless manner, many glands being usually involved at the same time. 
Kone of these suppurate as a rule. The appearance of the primary sore 
marks the beginning of the second period of incubation. 

Generally, in about a month after the glands enlarge, after the second 
period of incubation the secondary stage commences, an eruption appears 
scattered more or less uniformly over the whole body, associated with 
lesions of the mucous membranes and a general enlargement of the lym- 
phatic glands all over the body. 

Just before the outbreak of the first of the early eruptions some pa- 
tients suffer from a mild amount of fever, the temperature, generally 
moderate, in exceptional cases mounting quite high. Kheumatoid pains 
are often complained of — worse at night. Sometimes there is headache, 



200 VENEREAL DISEASES. 

a general fall of hair is often noticed (alopecia), and acute iritis may be 
an attendant symptom. 

The bodily health sometimes fails considerably during the first year, 
bmt it sometimes remains seemingly undisturbed. 

At the end of a year or more there is a natural lull in the course of 
the disease. There may be an entire absence of symptoms for many 
months. In very exceptional cases the lull remains permanent, and the 
patient seems to be and to remain well from that time on. Usually, 
however, after a period of quiescence more or less long, new outbreaks 
appear upon the skin, upon the fauces, and in the mouth. Periosteal 
pains in all the superficial bones are now apt to make themselves felt, 
chiefly at night, and a certain amount of failure in general health is cus- 
tomary. 

This state of things prolongs itself for a period varying from a few 
months to two years or more, and terminates by leaving the patient sound 
and well, or by merging into the next, the tertiary stage. 

In the last, or tertiary stage, the symptoms are exceedingly variable 
in intensity and extent. All the superficial and the deep textures of the 
body, as well as all of the internal organs, may be involved. The lesions 
of this stage, wherever they occur, are characterized by connective-tissue 
hyperplasia or by gummatous deposits, and in either case by thickening 
of the walls of arteries within the pathological areas. In the skin, 
patches of tubercles and serpiginous ulcers appear. Nearly all the lesions 
leave deep scars. The throat may be attacked by rapidly destructive 
gummy ulceration, the bones of the nose may necrose and come away. 
Ulcers may develop upon the mucous membrane of the stomach and 
intestine and impair nutrition. The liver, the lungs, the kidneys, the 
heart, all have their chance at suffering from tertiary disease, as indeed 
do all the internal organs and tissues. Nearly all known chronic diseases 
giving symptoms through the brain or through the nerves may be simu- 
lated by the symptoms of tertiary syphilitic disease of the brain and 
nerves. 

The bones and joints, and tendons, and bursse, and muscles furnish 
appropriate symptoms, as do indeed all the structures of the body. 

After yielding symptoms in the tertiary stage, more or less severe in 
type, sj'philis in course of nature declines spontaneously. But, before 
this period has arrived, such vital organs may have become involved in 
permanent changes in their structure that health is no longer possible, 
and sometimes life itself cannot be sustained. Death as a direct result 
of syphilis is uncommon in the adult, but may be produced by the occur- 
rence of structural changes in the vital organs, or by the cachexia of the 
tertiary stage. Cachexia is one of the marked phenomena of this stage, 
and sometimes seems to be independent of obvious organic changes in the 
tissues. 



SYPHILIS. 201 

Syphilis is full of surprises and characteristic irregularities. No two 
cases exactly resemble each other, and yet the family likeness is quite 
strong in all. Whole groups of customary symptoms may be omitted 
during the evolution of the disease. Symptoms may be strangely out of 
place. Tertiary manifestations appear in precocious cases a few months 
after chancre, while, on the other hand, erythematous and scaly spots 
upon the palms, the soles, and in the mouth may crop out long after the 
tertiary period seems to have come to a natural end. 

General Pathology. — The changes wrought by syphilis upon the organs 
and tissues of the body are very limited in number and very uniform in 
type, but the symptoms to which they give rise are as varied as are the 
functions of the organs and tissues involved. 

The pathological individuality of syphilis shows itself in the various 
stages of the disease by new connective-tissue production, cellular pro- 
liferation, and in the formation of gummata. These lesions involve first 
the subcutaneous tissue, later the walls of the blood-vessels, and finally 
the central nervous system. 

The roseola of syphilis is largely congestive; in the papule there is 
cellular infiltration as well. In the pustule and vesicle there is exuda- 
tion of pus and serum beneath the epidermis. The later cutaneous 
manifestations are, as a rule, gummatous. The tubercles, the ulcers, the 
gummata of the skin, are all essentially different varieties of gummatous 
infiltration. They all undergo, in the evolution of the lesion, retrograde 
changes — coagulation necrosis — due to the scarcity of blood-vessels in the 
areas containing them and to disease of the vascular walls. 

Of the three pathological types of lesions due to syphilis — new growth 
of connective tissue, arterial thickening, and the formation of gummata — 
the connective-tissue hyperplasia plays the most constant role. This 
tendency shows itself throughout the entire course of the disease, and is 
the basis of the morbid changes which take place m all parts of the body. 

One of the commonest expressions of late syphilis is the production 
of new connective tissue in the central nervous system. Its elements, 
consisting of round and polyhedral cells, appear in patches of circum- 
scribed tissue, accompanied by more or less congestion. Later on the 
blood recedes from the congested vessels, the new tissue becomes con- 
densed and atrophies, and sclerosis is the result. 

But there is nothing specific in this form of connective-tissue hyper- 
plasia. Other forms of sclerotic change closely resemble it. 

The gummy tumors or gummata are characteristic of syphilis and be- 
long to the clinical history of the tertiary stage. They are formed of a 
collection of small, soft, round cells, which lie very closely crowded 
together in among the elements of the other tissues, which they push 
aside. 

Such collections of cells may develop in any place where connective 



202 VENEREAL DISEASES. 

tissue and blood-vessels are found — in short, almost anywhere in the 
body. Gummata commence to form usually around small blood-vessels 
or in the adventitia of large ones, and are found of minute size scattered 
along the fibrous septa of an organ in connection with more or less general 
connective-tissue hyperplasia, or as a single large nodule of independent 
formation. 

The connective tissue around a large gumma becomes condensed and 
thickened into a sort of fibrous envelope; its central portion is necrotic 
and undergoes caseous degeneration. This is either due to lack of blood 
supply or to the action of toxins produced by the presence of specific 
micro-organisms, the nature and character of which have not as yet been 
discovered. 

Gummata situated near the surface generally tend to act like abscesses, 
to soften centrally and then ulcerate their way to the surface, discharge 
and eliminate themselves in the form of gummy ulcers. 

The other pathological change produced by syphilis is a modification 
in the walls of the blood-vessels. We find the vessels surrounding the 
primary lesion infiltrated and thickened with proliferated round cells. 
Such a condition is also a constant accompaniment of all inflammatory 
conditions, but especially characteristic here. A large share of the mor- 
bid phenomena which occur in brain syphilis is due primarily to changes 
in the walls of the arteries of the brain, commencing as an endarteritis, 
and culminating in a thickening of the wall of the vessel and obliteration 
of its calibre. The syphilitic endarterial changes occurring in the 
different large arteries of the body result in thickening of the arterial 
tunics and in the formation of thrombi. Eetrograde metamorphosis and 
gummata lead to weakening of the vessel wall and are a direct cause of 
aneurism. 



CHAPTEE V. 

THE TRANSMISSION OF SYPHILIS. 
Methods of Contagion — Prognosis. 

That syphilis is due to a specific virus is generally conceded, although 
its nature and character are still undergoing investigation. 

An assumption of a specific poisonous quality in that which is the 
essence of syphilis serves practically to assist in accounting for its phe- 
nomena and in explaining its analogy to other infectious diseases. 

Secretions which Contain the Syphilitic Poison. — The thin serous 
secretion of a syphilitic chancre contains the poison probably in as con- 
centrated a state as it can be furnished by the economy. The contagious- 
ness of chancre and its clinical hetero-inoculability in kind upon a virgin 
subject have never been doubted, since the initial lesion of syphilis has 
been recognized as the starting-point of the disease. 

The contagious properties of secretions from mucous patches and 
secondary ulcerated surfaces upon mucous membranes have become so 
obvious, clinically, that it is questionable whether this lesion does not 
divide the honors of propagating syphilis equally with chancre. Mucous 
patches and mucous tubercles, ulcers of the mucous surfaces — all these 
lesions secrete freely and are in a position frequently to be brought into 
contact with surfaces capable of absorption. The long duration of these 
lesions makes them especially dangerous. They last for months at a 
time, and relapse frequently while the syphilitic chancre, for the most 
part, occurs upon a patient but once in a lifetime, and is of comparatively 
short duration. Abrasions may be inoculated during sexual contact as 
well from a mucous patch as from a chancre. 

Nearly all the examples of the primary lesion of syphilis encountered 
upon the mouth or on the face, the primary lesion of a suckling child 
derived from a syphilitic nurse, of a healthy nurse from an infant with 
inherited disease, the cases of syphilis acquired from using spoons, pipes, 
glass-blowers' tubes, those communicated by the surgeon through the 
instrumentality of the Eustachian catheter, the digital chancre of the 
accoucheur — in all of these, quite certainly in most instances, the vehicle 
of the poison has been the secretion of a mucous patch. 

Hetero-inoculations of syphilitic blood, and of pieces of solid tissue, 
which of course contain blood, have been made experimentally by a num- 
ber of physicians. Some of the inoculations have taken ; others yielded 



204 VENEREAL DISEASES. 

only negative results, showing that the intensity of the poison in blood 
is not particularly great. In former days, before the present advanced 
methods of vaccination with bovine virus were employed, epidemics of 
" vaccinal syphilis " were not uncommon. In this instance the blood is 
the vehicle of contagion. 

The danger of transmission under the same circumstances is still to 
be feared if a scarifying instrument be used in vaccinating and proper 
antiseptic precautions are not observed. 

Clinically, cases are encountered in which blood seems to be the vehicle 
of contagion — in which, for instance, a man acquires chancre, and confron- 
tation fails to detect any physical lesion in the female. It is probable that 
the virulent quality of the blood in syphilis moderates in the later stages 
of the disease and under the influence of treatment. 

The secretions from tertiary lesions of syphilis, serpiginous ulcers, 
lesions of bone, etc., do not seem to retain any inoculable quality, so far 
as the transmission of syphilis is concerned ; but with the tertiary secre- 
tions, as with non-syphilitic pathological secretions upon syphilitic per- 
sons, it is well to reserve judgment for a time. They may possibly be 
capable of carrying the poison of syphilis without admixture of blood; 
but it has not yet been proven that they do so. 

Of the i^hysiological secretions it may be quite confidently affirmed that 
none of them is able to communicate syphilis by inoculation. 

The tears, the urine, the saliva, the perspiration, the milk, the 
semen, have all been repeatedly inoculated without success. Some dis- 
pute has been raised upon the last two physiological secretions regarding 
their power of inoculation. 

The apparent infections by milk recorded by a number of observers 
are more than set off by carefully observed cases in which children have 
suckled syphilitic nurses and remained sound, while inoculations of milk 
directly prove its lack of noxious quality. If the nursing syphilitic 
woman has a mucous patch, and the child a fissure on the lip, then the 
whole premises are changed, and chancre on the lip of the child is the 
natural result. 

The infectious quality of semen is a matter of serious dispute, both 
as to its direct contagious properties and its capacity by impregnation to 
infect the offspring, the mother remaining healthy. 

The evidence at best is only negative. A little blood may very easily 
escape from an abrasion in the male and carry the poison along with the 
semen. The mass of clinical evidence is enormous, going to show that 
men in full syphilis, but without local lesion, may have intercourse with 
impunity, and may even impregnate healthy women, and not transmit 
syphilis to them at all, or even to the offspring. That the semen, how- 
ever, can transmit syphilis by inheritance seems to be pretty conclusively 
proved, but it certainly does not always do so. 



THE TRANSMISSION OF SYPHILIS. 205 

In connection with the study of the virus of syphilis, and of the fluids 
which contain it and may transmit it, the question of transmission by 
inheritance naturally comes to mind. 

When both parents are diseased, the child is quite certain to be syph- 
ilitic, unless the poisonous quality of the malady in both parents, and 
especially in the mother, be pretty nearly exhausted. Cases have been 
recorded in which the child appeared sound in spite of disease in both 
parents ; and all records dealing with this question refer to cases in which, 
the mother being diseased and producing a number of children, some of 
these suffer but little, if at all, while others, born later, are manifestly 
syphilitic. It is certain that a syphilitic woman under treatment may 
produce a child in all respects healthy, and then, giving up medicine 
under the idea that she is well, may give birth later to a child about 
whose syphilis there can be no doubt. 

In the majority of instances, syphilis exhausts itself by lapse of time 
in the mother, and her children become less and less likely to be diseased. 

When the woman alone is syphilitic, the child is quite certain to in- 
herit the disease. Exceptions to this rule have been alluded to above, 
in which the mother has syphilis, then produces a healthy child, then a 
syphilitic one. ^ 

When the father alone is syphilitic, the child unquestionably often 
escapes if the mother remains well; corroborative cases are constantly 
turning up, and there can be no reasonable doubt of the fact that a healthy 
woman, by a syphilitic man, may have a healthy child. 

But that a healthy woman by a syphilitic man must have a healthy 
child, is altogether another question, and certainly is not a fact, if there 
is any value in evidence. 

It seems fair to accept as proved that a syphilitic father may pro- 
create a syphilitic child, and that, if the mother at the time of conception 
is healthy, she may remain so, or seem to remain so, indefinitely, the 
child being born syphilitic. 

This statement leaves two weak points unsatisfied by explanation. 
The points, both negative, are these: in no case reported has it been 
shown that a healthy mother, who had produced a syphilitic child dis- 
eased from its father, afterward became herself poisoned by experimental 
or accidental inoculation. The other point is this : Colles' law, so called, 
states that a child with inherited disease may poison a healthy stranger 
whom it suckles by inoculating the breast ; but that the same child can- 
not poison its mother. This rule cannot possibly stand, unless the 
mother is already syphilitic, or unless the child has conveyed to the 
mother an immunity to the disease. No authentic instance has been 
recorded in which, among the great number of cases observed, any excep- 
tion to Colles' law has been noted. Caspary attempted the only possible 
1 Vrtljhrschrift f. Derm, u, Syph., 4tes Heft, 1875. 



206 VENEREAL DISEASES. 

positive solution to this question. He found a seemingly healthy woman 
with a syphilitic husband and a syphilitic child. He inoculated the woman 
with the secretion of syphilis without effect, thus seeming to prove that 
although apparently healthy, she already had syphilis. 

In summary of the foregoing statements, it seems just to conclude : 

1. When both parents are syphilitic, the child is almost necessarily 
diseased. Exceptions are probable under treatment of the mother, or 
when lapse of time has exhausted the disease in the mother; exceptions 
are possible during lulls in the disease, or under circumstances with 
which science is at present unfamiliar. 

2. When the mother is diseased and the father healthy, the child is 
syphilitic, excepting under the same circumstances as obtain when both 
parents are diseased. 

3. When the father is diseased and the mother healthy, the child may 
be syphilitic and may be healthy. Sometimes the child is diseased under 
these circumstances, while the mother seems to he and continues to remain 
well in all respects, as testified to by a number of perfectly competent 
observers. 

In connection with this question of the transmission of syphilis by 
inheritance, three other points must be considered, namelj'', the date at 
which a woman, carrying a child, may become syphilitic without poison- 
ing the child ; the " choc en-retour " of Eicord ; and the transmission of 
syphilis to the third generation. 

Unless the mother, who has been healthy and carries a healthy child, 
gets a chancre before the seventh month of pregnancy, it is believed that 
her child will escape (E-icord, Boeck, Barensprung, Frankel, and others). 

If the mother gets her chancre at the moment of conception, or soon 
after, she is apt to miscarry. If she gets it later, the child goes to term, 
but is born thoroughly poisoned, with poor chance of surviving. The 
common agreement is that if the chancre does not appear before the 
seventh month, the child is safe. This, however, is not always the case. 

Choc en-retour is a fanciful expression, meaning that a healthy woman 
conceives by a syphilitic man, that the ovum becomes diseased through 
impregnation with diseased semen and in its turn poisons the mother, the 
latter never having any chancre, but becoming contaminated by the action 
of toxins circulating through the blood which are generated in the infected 
fluids of the foetus. 

The possibility of choc en-retour reopens the whole question of the 
inheritance of syphilis from the father alone, already discussed above. 
The possibility of this method is seriously doubted by many, steadfastly 
believed in by others. It will stand or fall upon a final and definite 
solution of the question of inheritance from the father alone. If the 
father can transmit syphilis to his offspring by some quality his malady 
has imprinted upon his spermatooza — and there is no reason to believe 



THE TRANSMISSION OF SYPHILIS. 207 

that this is impossible — then it is very probable that choc en-retour 
exists, and that the prolonged presence of the child in utero necessarily 
poisons the mother, without chancre, giving her perhaps a modified form 
of the disease — not enough poison to betray itself by the usual symptoms 
of syphilis, but enough to protect her from acquiring the disease after- 
ward in a natural way, or by inoculation (Caspary), and preventing her 
child from giving her chancre of the breast, thus justifying Colles' law. 

The transmission of syphilis to the third generation has generally been 
doubted. Several alleged cases have been reported, some of which seem 
to be unwarranted assumptions, while in others the history is incomplete 
and unsatisfactory. The theory that syphilis having been once trans- 
mitted by inheritance degenerates into something like scrofula, and is. 
transmitted as such, cannot be sustained. 

Enough evidence from different quarters has not been collected to de- 
clare that syphilis may be transmitted to the third generation, although 
such a possibility is not out of the question. 

Methods of Contagion, — The methods by which syphilis may be ac- 
quired are many. 

It may be acquired by contact of a surface capable of absorption, upon 
any part of the body, with the poison of syphilis contained in any fluid 
capable of holding it, whether it be upon the body of the person yielding 
the poison or upon some indifferent object. Thus its transmission may 
occur by means of direct or mediate contagion. 

Syphilis acquired by sexual intercourse in the usual way is an instance 
of direct contagion. The surface capable of absorption upon the healthy 
person is brought into direct contact (usually) with the source of the 
poison. But there are many methods of direct contagion other than that 
by sexual intercourse. As illustrating these methods may be instanced : the 
chancre of the lip, acquired by kissing, a mucous patch being the source 
of the poison ; the digital chancre of the surgeon, acquired while mani- 
pulating poisoned parts ; or of the accoucheur, acquired while practising 
the vaginal touch ; the chancre on the nipple of the healthy nurse, taken 
from the mucous patch in the mouth of the syphilitic child, and vice 
versa. 

As an instance of mediate contagion the following example may be 
quoted: A married man with a long prepuce has intercourse with a former 
mistress. He returns home unwashed, and repeats the sexual act with 
his wife, leaving in her vagina some syphilitic secretion which he had 
obtained from the mistress, and carried in the folds of his prepuce. 
The man escapes infection, but his wife acquires chancre. Spoons and 
forks, cups and tobacco-pipes, tattooing-needles, are well-known media 
of contagion, receiving saliva which contains the secretions from mucous 
patches in the mouth, and depositing it upon a fissure in the lip of 
another person. In the industry of glass-blowing, the passage of the 



208 VENEREAL DISEASES. 

tube from mouth to mouth has been known to effect a widespread distri- 
bution of the poison. Vaccination as a means of mediate contagion has 
already been noticed. Surgical instruments have sometimes been the 
medium of contagion. Wet-cups have carried the disease, the transplan- 
tation of teeth has done the same, and the practice of the religious rite of 
circumcision. 

A knowledge of the variety of methods by which syphilis may be con- 
veyed is of great value to the patient, who is ordinarily ignorant of it. 
It is well to instruct him in this, as well as to give him directions about 
the local and general treatment of his disease, so that, while curing him- 
self, he may know how to preserve those by whom he is surrounded from 
.infection. 

Syphilitic Reinfection. — It is notorious that a patient while syphilitic 
cannot take the disease. Thousands of inoculations have been made upon 
such patients by hosts of experimenters. Protection against future attacks 
is secured by a single infection ; and yet there are a number of cases on 
record, resting on evidence which silences criticism, proving that true 
syphilis may be acquired twice by the same individual, and may in one 
lifetime run through its different stages twice. It follows that the first 
syphilis must be well, or the second could not have been acquired. 

Second attacks of true syphilis unquestionably do occur. This fact is 
not more strange than that of second attacks of other maladies, such as 
smallpox, scarlet fever, measles, vaccinia, etc., one course of which gen- 
erally protects a patient for life. 

An attentive reading of many cases of so-called second infection makes 
it clear that there is no second attack at all, but that some forms of pseudo- 
chancre exist which are not at all uncommon, such as ulcerated gumma, 
herpes, and relapsing induration at the site of the original sore. 

While, then, it must be granted that second attacks of true syphilis 
do occur, although very exceptionally, it is fair to conclude that many of 
the reported cases are instances of one of these forms of pseudo-chancre, 
and not second attacks of syphilis at all. 

Prognosis. — Practically, in the majority of instances, syphilis is a 
mild disease. It gets well, to all intents, under a variety of treatments, 
or under no treatment at all very often ; and the main advantage pos- 
sessed by one treatment over another is the power which it may give of 
immediately controlling symptoms which directly threaten life, limb, or 
functions, and the guaranty afforded by experience in its use against 
relapse or serious disease late in life. 

Therefore, allowing that bad cases may continue to relapse almost 
indefinitely, and that some late lesion, due to syphilis, may occasionally 
appear after any treatment upon a patient once affected, even possibly up 
to the hour of his death, yet the common duration of the disease is only 
about two and a half to three years, and many cases do not have symp- 



PROGNOSIS. 209 

toms longer than during a few months. After the first year or year and 
a half, there is generally but little trouble; and when the disease has 
fairly died away the patient is as well as ever, and may go on to a ripe 
old age without ever again hearing of his enemy, having healthy children, 
and passing through the changes incident to advancing life exactly like 
any one else. 

Uncertainty as to what the disease may eventually do interferes seri- 
ously with accuracy of prognosis of syphilis. The old notion, therefore, 
that a light beginning in syphilis can be counted upon to indicate a type 
of disease in itself necessarily mild, is not accurate. As far as the first 
symptoms show anything, however, they do in a measure declare the 
character of the subsequent symptoms, but they do not guarantee it ; the 
element of treachery steps in, and no honest prognosis can be a very 
positive one. 

A long incubation to the chancre, mildness in the primary lesion, a 
long secondary incubation, mildness in the earliest eruption (roseola) are 
qualities in the early symptoms which generally indicate a mild type of 
disease. 

On the other hand, a short incubation to the chancre, severity m its 
symptoms or the duration of th3 latter, intensity in the local character 
of the first outbreaks (pustular instead of erythematous), and resistance 
of the latter to treatment — particularly that form of disease in which 
symptoms usually occurring in the tertiary stage come on early in the 
course of the malady — all of these features in the beginning of syphilis 
indicate severity in the type of the disease, and the prognosis must be 
modified accordingly. 

It often happens that cases mild in the quality of their symptoms are 
severe in regard to duration. 

The influence of constitution upon the course and the type of syphilis 
is very obvious. Two persons infected from the same source do not have 
exactly the same type of disease. Both acquire identically the same 
poison, but the symptoms are quite certain to run a different course. 

In a general way, it is true that a healthy person in good hygienic 
surroundings, living a regular life, is best able to stand an attack of 
syphilis, and ought to escape lightly; while a sickly person, in bad sur- 
roundings, should by right be overwhelmed by the disease. This is in 
a measure true, but exceptions are too common to make the fact of much 
value. A vigorous youth in the flower of health may wilt under the 
blight of syphilis, while a puny consumptive or a white-blooded dyspep- 
tic suffers very little more while the disease is upon him than he did 
before he acquired it. 

Despite exceptions, constitution does, on the whole, modify the course 
and intensity of the symptoms of syphilis. The rheumatic and the scrof- 
ulous tendencies are obvious in their effects upon the symptoms of the 
14 



210 VENEREAL DISEASES. 

disease. In the individual of so-called gouty habit, the evolution of the 
disease is slow, the type of eruptions dry and scaly, chronic, relapsing, 
often quite superficial. Pains and joint troubles, iritis, and bone disease, 
arterial complications leading to brain symptoms, are more to be expected 
in this class of patients. 

The condition of patients v^rith phthisical tendencies is nearly always 
aggravated by an intercurrence of syphilis. 

Patients who are lymphatic, and who readily suppurate from injuries, 
the effect of which would be easily thrown off by another, have moist 
vesicular and pustular lesions early in the disease for the most part, and 
are prone to run early into ulcerative lesions. 

Syphilis influences the healing of fractures. Cases are reported 
in which firm union was delayed until the patient had been put under the 
influence of large doses of the iodide of potassium, although at the time 
the patient was not suffering from any obvious symptom of syphilis. 

Sometimes ordinary wounds upon a syphilitic person fail to do well, 
and if irritated, assume the character of syphilitic ulcers. This tendency 
is decidedly lessened by the observance of strict antisepsis in the treat- 
ment of all traumatisms upon syphilitic subjects. 

Prostrating and excessive work, irregular habits, excess of any kind, 
dissipation, bad hygiene, poor food, insufficient clothing, over-treatment 
(by excess of drugs), under-treatment (of too short duration), no treat- 
ment, bad treatment — all tend to aggravate the general prognosis. 

Sex also influences the prognosis. Women are more apt to become 
anaemic than men, and to grow greatly debilitated. The duration of 
syphilis with them, and the periods of latency, are seemingly longer. 

The age of a patient certainly influences prognosis. The activity of 
the disease is very great in babyhood, and young children very frequently 
die of syphilis, inherited or acquired. Old people, on the other hand, 
have less vitality and power of resisting disease, and syphilis acquired in 
advanced life is therefore often severe. 

The truth is that syphilis is in most cases a very manageable disease, 
and prognosis is more influenced by the intelligence exercised in treating 
it than it is by all other circumstances combined ; but there are occasional 
exceptions to this rule, as there are to all others relating to syphilis. 



CHAPTER VI. 

THE CHANCEE— PRIMARY LESION OE SYPHILIS. 

The incubation of syphilis is that period of rest which always occurs 
between the absorption of the virus and the appearance of the chancre at 
the spot where absorption took place. This is termed the^r^^ period of 
incubation. Its average duration is twenty-one days, and it has been 
known to occupy nearly all the intermediate points between ten and 
sixty, or even seventy days ; but such long periods are decidedly excep- 
tional. The rule is that the disease generally makes its appearance in 
the primary sore within four weeks after exposure. 

This local outbreak in syphilis always occurs at the point of entrance 
of the poison, and the disease continues, apparently, confined to this 
point for a period of so-called second incubation, after which the symp- 
toms of the disease become generalized. 

The initial lesion or first stage of syphilis is a chancre, which 
appears after a period of incubation upon the spot at which the poison 
was first absorbed. It occurs clinically under a variety of forms which 
resemble each other very little. There is indeed nearly as great a 
variety in the local expression of primary syphilis as is known to be the 
case in secondary syphilis. Chancres, as encountered clinically upon the 
male and female genitals, are; (1) the raw erosion; (2) the superficial 
ulceration; (3) the deep, funnel-shaped ulcer, always indurated; (4) the 
herpetiform chancre ; (5) the mixed chancre. The syphilitic chancres of 
the lip, of the nipple, of the general integument have their type-forms, 
and also chancres of the urethra, anus, or rectum. 

The Raw Erosion. — This is the most common form of syphilitic chancre. 
Most estimates place its occurrence as high as sixty to seventy -five per 
cent of all forms. It is found in both sexes on the integument, as well 
as upon a mucous or semi-mucous surface. It is of variable size from 
that of a small split pea to a large beefy patch as big as a copper penny 
when advanced in growth. The surface may be any shade of red, occa- 
sionally a light subdued pink. Generally the color approaches a livid 
purple, and later on becomes coppery. There may be a central adherent 
false membrane, but usually the surface is literally raw; not discharging 
pus, not ulcerated, but yielding a trifiing discharge of bloody serum. 

In shape this erosion is oval or irregularly rounded ; perhaps it may 
run along a natural fissure. Several may occasionally coexist upon one 
patient, appearing simultaneously. Induration of these erosions is com- 



212 VENEREAL DISEASES. 

mon, sometimes partial, sometimes beneath the whole surface, often 
parchment-like and imperceptible unless the whole integument at the seat 
of the erosion be lifted up, and the lesion gently pinched laterally between 
the thumb and finger. Sometimes, on the other hand, the induration is 
verjT- prominent and bulges up above the surface like a solid tubercle, 
with a flat, raw top (ulcus elevatum). 

The Superficial Ulceration, — This form of primary lesion is very com- 
mon, and is much like the last in most of its features. In fact, many 
chancres are first erosions, then ulcerate superficially, and perhaps later 
return to the eroded state. The only difference between this chancre and 
the erosion is that this form is ulcerated. The ulcer is slight, its borders 
are adherent and sloping. Its underlying induration may be parchment- 
like, is more apt to be of split-pea variety, or there may be an elevated 
tubercle with a dome-like, ulcerated cap. Finally, the induration may 
be slightly excavated downward, and then the ulcerated surface is cor- 
respondingly depressed. The floor of these ulcers is grayish, the dis- 
charge scanty, thin, sero-purulent — perhaps bloody. 

The Hunterian chancre, formerly looked upon as a type, is almost 
rare enough to be an exception. It is simply a very pronounced chancre 
of this last variety, in which the induration is considerable and the excava- 
tion proportionately great. The chancre is a large mass of woody in- 
duration, of rounded form, in the centre of which is an oval or rounded 
ulcer extending deeply into the induration, funnel-shaped, with a pulta- 
ceous floor, adherent sloping edges, and yielding a thin, moderate, puri- 
form discharge. 

Herpetiform chancres, so called, consist of a collection of chancrous 
erosions. They resemble clusters of herpetic vesicles and may be mis- 
taken for them. On this account in doubtful cases an opinion should be 
guarded. The diagnosis is made by the persistency of the lesions, mode- 
rate induration, and, later, involvement of the inguinal glands. 

The mixed chancre is a combination of the two sores, the chancroid 
and the syphilitic chancre. Each sore runs its course, and the compound 
lesion possesses the characters of both. 

A mixed chancre may result from the inoculation of either sore upon 
the other, and its characters will be correspondingly modified according 
to the period of development of either sore ; either one msij be nearly well 
before the other gets fairly under way. If the compound poison is in- 
oculated, the chancroid would naturally be well along in its course before 
it assumed any syphilitic features. The mixed chancre has been produced 
experimentally. 

Inoculation of the secretion upon a healthy subject clinically may pro- 
duce chancroid alone, or mixed sore. 

Chancre of the general integument occurs as a flattened papule or ele- 
vated tubercle, or excoriated patch, or a moist, flat tubercle, or an indu- 



PRIMARY LESION OF SYPHILIS. 213 

rated ulcer. All of these forms have been seen and studied in connection 
with experimental auto- and hetero-inoculations, and they may be en- 
countered clinically. The lesions resemble the same varieties upon the 
penis. The excoriations are often in part or totally scabbed over j there 
may be nothing more than an insignificant, dry, scaling papule upon the 
skin to mark the point of entrance of syphilis. The flat, moisu tubercle 
resembles exactly the condyloma — the flat, mucous tubercle of the skin. 
Finally, a superficial or a deep excavated ulcer may ipark the starting- 
point of syphilis upon the skin, and in such case the induration of the 
ulcer is apt to be quite extensive. 

Chancre of the lij) is generally a globular mass of induration as large 
as a marble, with an excoriated or exulcerated surface. 

Chancre of the tongue has no distinctive characteristics, but resembles 
the raw erosion found upon the genitals. It is generally located on the 
dorsal surface and sometimes on the side of the lingual mucous membrane. 
Its surface may be shiny and red or covered by a membranous film. The 
submaxillary glands are always enlarged. 

Chancre of the tonsil is not of frequent occurrence. When it does 
occur it is characterized by a thick, indurated, brawny swelling, some- 
times with an eroded surface, sometimes ulcerated and covered with a 
whitish or greenish exudation. 

Chancre of the niijple acquired by nursing a syphilitic child may be a 
large, deep, indurated ulcer, a brawny excavation, an excoriated or ulcer- 
ated, indurated fissure, or a flat, mucous papule more or less livid, moist, 
or dry, scaly or scabbed, sometimes but little indurated. 

Urethral chancre may be observed through the endoscopic tube in the 
form of a rounded erosion or flat ulcer. Generally, urethral chancre is 
situated just within the meatus, one or both lips of which it may involve. 
Occasionally, however, it occurs at a considerable distance within the 
canal. 

Sometimes the existence of urethral chancre is disclosed by the presence 
of a lump along the course of the urethra, usually painful upon erection. 
At this spot some pain is apt to be complained of on urinating. A slight 
discharge flows from the urethra, more mucoid than purulent, sometimes 
bloody. This discharge commences at a considerable interval after the 
sexual contact to which it was due. The slight discharge continues for a 
number of weeks, and the scar left by the chancre may subsequently occa- 
sion more or less stricture of the urethra. The inguinal ganglia are in- 
dolently enlarged and indurated. 

Chancre of the fingers occurs at the site of an abrasion or hang-nail on 
the hands of surgeons or nurses. The notable feature of such a sore is 
the great amount of thickening surrounding it, with an absence of definite 
ulceration. The surface is raw, shiny, red. The epitrochlear and axil- 
lary glands are indurated and enlarged. 



214 VENEREAL DISEASES. 

Chancre of the anus is found around the margin of the sphincter in 
one of the folds. On this account and because the induration is not 
generally great, this lesion may go unnoticed. As an irregular ulcera- 
tion or erosion it approaches in type a similar lesion on the general 
integument. 

In the female, around the ostium vaginae and on the labia, erosions, 
often not appreciably indurated, excoriations, flat, raised mucous tuoer- 
cles, and the regular deep indurated ulcer, may each be encountered as 
the herald of future syphilis. 

Upon the cervix uteri the chancre usually appears on the anterior lip 
as an elevated or flattened erosion, with a red areola and covered with a 
membranous pellicle. 

Course. — The first evidence of inoculation of syphilitic virus upon the 
skin of a healthy subject is a flat, dry redness, or a raised, hard papule, 
red on top. Generally, upon a mucous membrane, an excoriation or a 
small superficial ulcer is found from the start. Sometimes a mass of 
induration forms first, and this afterward excoriates or ulcerates. On a 
mucous membrane a vesicle or a pustule may precede the shedding of the 
cuticle which leads to the excoriation, but its existence is ephemeral. 
Induration of the base may precede the breakage of the cuticle, and be 
excessive as compared to the latter ; or the opposite condition may obtain, 
there being considerable ulceration after matters have progressed for a 
time and very little hardness. Exceptionally, the whole prepuce becomes 
stiffened with a cartilaginous induration. An acute livid flush of the 
integument may precede this induration, or the latter may form gradually, 
especially if the chancre involves the prepuce near the frenum. 

The erosion or ulcer increases in size for a varying period and to a 
varying extent; from an erosion, through irritation, it often becomes an 
ulcer. It remains unique, not poisoning the integument in the neighbor- 
hood, and not giving any pain ; yielding its watery discharge, attended 
by its lymphangitis and its adenitis in the second week, and, after last- 
ing from two or three weeks to as many months, it finally gets well, leav- 
ing no trace in most instances. If the ulcer, however, has eaten through 
the papillary layer of the skin, if it has been phagedenic at all, then a 
scar is left, proportionate in extent to the amount of tissue destroyed. 
These scars often remain indurated for a considerable period. They are 
not customarily pigmented. 

Induration is a feature of chancre the importance of which has been 
much overrated. It is not an absolute essential of syphilitic chancre, 
although unquestionably it is a very constant symptom. Induration 
occurs in several forms : 

The most common is the parchment-like induration found underlying 
an ulcer or an erosion, and often appreciated with difficulty, unless the 
ulcer be pinched up laterally between the thumb and finger. This 



PRIMARY LESION OF SYPHILIS. 215 

variety of induration is common in the female ; it is rarely simulated in 
other forms of disease ; it does not involve the subcutaneous or submucous 
tissues. 

The next form is characteristic, but not very common. It is called 
the split-pea induration. Immediately underlying the ulcer is a sub- 
stance of cartilaginous or woody hardness, like a split pea, convexity 
downward. Its size varies with the size of the surface lesion. It is very 
nearly, indeed often absolutely, insensitive to moderate pressure. It 
does not shade off into the tissues around it. It is not adherent to the 
deep fascia, but it ends abruptly in all directions, and is as cleanly de- 
fined as would be a foreign body set into the skin attached to the ulcer 
by its upper surface. 

The last form of induration is excessive. It resembles the previous 
variety m its quality and behavior as to the surrounding tissues, but it 
may greatly surpass the limits of the surface lesion, be convex or con- 
cave on its surface, or involve irregular areas of skin, as when the whole 
prepuce or a portion of it is involved in a wood-like hardness in connec- 
tion with chancre. 

Induration often precedes the breakage of the skin, and very often, 
when it has been excessive, outlasts the healing of the ulcer, continuing 
perhaps for several months, or in the scar for years. It may be of only 
short duration — ten or twelve days, coming late and going early. The 
thin, parchment-like induration is the most transitory. Once com- 
mencing to disappear, induration may relapse, and occasionally out- 
standing indurations appear in the neighborhood not connected with 
the initial lesion, but formed around the lymphatic vessels, and these 
indurations may possibly ulcerate (Fournier). Phagedsena destroys in- 
duration. 

Something like any of the above forms of induration may appear with 
other lesions than chancre, and indeed upon persons not at all syphilitic. 
It is never safe to depend upon this sign for a diagnosis. It is most 
valuable as a corroborative symptom, and more constant as a symptom 
of syphilitic chancre than any other one symptom, except the length of 
the period of incubation ; and this latter may be unattainable. Ordinary 
inflammatory induration generally is very different from specific indura- 
tion. It is red on the surface, painfully sensitive to pressure, adherent 
to the skin and the parts beneath, losing itself gradually in the subcu- 
taneous tissue, with no clearly defined edge; yet, in spite of all the 
differential characters, syphilitic induration may be so closely simu- 
lated by a non-syphilitic lesion that, alone and without strong cor- 
roborative evidence, it is not of enough value to establish a diagnosis of 
syphilis. 

The induration of a small gumma of the semi-mucous membrane of 
the prepuce, as appreciated by the finger, is sometimes absolutely, and 



216 VENEREAL DISEASES. 

in all respects, a typical induration as found in the best-marked cases of 
syphilitic chancre. 

Syphilitic chancre is rarely complicated. Vegetations may grow up 
around it and its new surface may granulate, or may take on a whitish or 
necrotic pellicle. Some amount of inflammatory disturbance may com- 
plicate the ordinarily indolent and undemonstrative chancre, leading to 
its swelling, pain, suppuration, and giving to it some of the features 
(auto-inoculability) of its more formidable local rival, chancroid. All 
of these complications need but to be mentioned to be understood. The 
rarer complication of chancre with chancroid has been described (mixed 
chancre). 

Phagedsena complicating syphilitic chancre occurs usually in the gan- 
grenous form. If the whole base of the sore is involved, the induration 
disappears in the phagedenic process. Sometimes the slower form of 
phagedsena is found, but generally this variety is not very extensive, 
when complicating a syphilitic primary lesion. A description of both 
forms of phagedaena has already been given in connection with chancroid, 
and nothing further need be added here except an allusion to the fact 
that mercury internally, although harmful to phagedsena occurring upon 
the patient who is not syphilitic, is decidedly beneficial to the phagedaena 
attacking syphilitic chancre. 

It is generally believed that a phagedenic chancre portends a bad type 
of syphilis, and this is doubtless so, since phagedsena is not a quality of 
the peculiar virus with which the patient has been poisoned. The phage- 
dsena is due to the patient's own quality of constitution, and it is fair to 
suppose that such a constitution will suffer from an attack of syphilis 
more seriously than another. 

Lymjphangitis. — This consists in an indolent thickening, with indura- 
tion of the wall of one or more lymphatic trunks. The thickening in- 
volves a certain amount of the surrounding perivascular connective tissue. 
These rigid cords with occasional knots upon them may be felt along the 
sides or back of the penis, sometimes part way from the chancre back- 
ward toward the root of the penis, sometimes only perceptible near the 
pubic symphysis. The cords vary in size with the amount of infiltration 
of the walls of the lymphatic trunks, and are larger, according to the 
amount of perivascular tissue involved. Very rarely the inflammatory 
process around the vessels goes on to suppuration. Generally the lym- 
phangitis, if it occurs, precedes the inguinal adenitis by a few days. It 
is, as a rule, painless, and of not the least importance. The integument 
over the thickened lymphatic trunks is not reddened. There is no pecul- 
iar character by which this malady may be known from a chronic mild 
lymphangitis of the larger lymphatic channels occurring spontaneously, 
and having no connection with syphilis as a cause. All that can be said 
of syphilitic lymphangitis is, that if it occurs with syphilitic (uninflamed) 



PRIMARY LESION OF SYPHILIS. 217 

chancre, it is very certain to be peculiarly indolent and painless, and to 
be characterized by a high degree of induration. Pathologically the 
lymph spaces are infiltrated with hyperplastic exudation. Syphilitic 
lymphangitis requires no treatment. 

Syphilitic Bubo. — The first set of lymphatic glands along the line of 
absorbents which originate in the neighborhood of the initial lesion of 
syphilis almost invariably become the seat of certain changes which 
stamp them with peculiar value as aids to the diagnosis of the nature of 
the primary lesion. The bubo of syphilis may therefore be situated any- 
where upon the body where there is a lymphatic gland, provided the 
radicals of the lymphatic trunks leading to that gland originate in the 
neighborhood of the chancre. Thus chancre of the lip has its bubo under 
the jaw; chancre high up on the cheek, in the pre-aural gland; of the 
hand, in the epitrochlear gland ; of the breast, in the axilla : of the penis, 
in the groin, etc. 

The syphilitic bubo almost invariably comes on during the second 
week after the appearance of the primary lesion, between the eighth and 
eleventh days in cases of experimental inoculation. One gland generally 
first becomes enlarged, and then a number of others, until (in the groin) 
a cluster of altered glands, not matted together, but lying separately, are 
found, constituting what has been termed a "pleiad," and, when typical, 
very distinctive of syphilis. 

The number of glands in a pleiad varies from two or three to six or 
eight. Where there are many, one is usually larger than the others. 
Generally the glands in both groins are involved. Each of the little 
glands of the altered group is quite hard, round or oval, painless on press- 
ure, not adherent to the skin or to the tissues lying under or around it, 
and each is entirely distinct from the others. The skin lying over them 
is not reddened, and the size of each gland varies from that of a pea to 
that of a marble. When the number is considerable, the size of each 
is usually smaller than when there are but few. Occasionally, instead 
of the pleiad there is one very large, hard, oval gland, with one or two 
quite small ones; and still more rarely the bubo is single, an enormous 
lump as large as an ^<g^ existing in one or both groins. These lumps are 
composed of a mass of indurated hyperplastic tissue. 

The swelling of these glands is called indolent because of their slow 
course, their painless and non-inflammatory character. Very often, 
however, when they begin to swell they are slightly painful; and occa- 
sionally they go on to suppuration, either centrally or as a periglandular 
suppuration. 

While the syphilitic bubo is generally multiple, in certain situations 
it is more apt to be single, as under the chin, under the jaw, at the elbow, 
although in the latter situation there may be a secondary pleiad in the 
axilla. 



218 VENEREAL DISEASES. 

The duration of syphilitic bubo varies from a few weeks to a number 
of months. Sometimes the glands never subside to their original size. 
They are almost constantly present during the first eruption, and at this 
time they occasionally grow somewhat larger and harder. 

The treatment of syphilitic bubo is that of general syphilis. Ko 
treatment is called for until a general eruption comes on. Local measures 
are useless. If pain and inflammation appear as complications, these 
symptoms are to be appropriately met. 

Treatment. — When once the syphilitic poison has had access to the ab- 
sorbents, the patient from that moment has syphilis, and he is therefore 
diseased in his whole body several weeks before the chancre appears. 
The folly therefore and the uselessness of destroying the primary lesion 
with caustics or with the knife, and of any abortive measures seem 
obvious. 

Excision of the chancre, with the possibility of effecting a cure of the 
disease in this manner has been advocated upon the theory that the poi- 
son, after being absorbed, lies latent locally throughout the period of in- 
cubation, and then commences to increase in quantity, at first only locally ; 
that after a period it reaches the lymphatic glands, and there increases 
and multiples again, remaining local in its new position until, during the 
period of secondary incubation, it has had time to infect the general sys- 
tem, after which it becomes general and manifests itself by an eruption. 
This theory is not sustained by recent clinical and pathological studies of 
the morbid process attendant upon syphilitic infection, which have demon- 
strated conclusively the absolute futility of excision of the chancre, even 
with the adjacent ganglia, as a prophylactic measure. 

The same conclusion has been reached regarding the early use of 
mercury during the primary stage as a preventive treatment against the 
general development of the disease. It is not only hopeless to expect to 
curtail in the slightest degree the progress of the disease by such a course, 
but it is believed that a harmful influence may be exerted thereby, the 
later lesions becoming severe and obstinate to treatment, not to mention 
the possibility of errors in diagnosis which may involve both patient and 
physician in a serious dilemma fraught with doubt and uncertainty. 

The best course to adopt then for the primary sore of syphilis consists 
in local and expectant treatment. The parts may be kept clean by any 
mild antiseptic lotion and the sore treated with a moist or dry dressing. 
Black wash is much used. This is more suitable in the advanced stage 
of the ulcer. A mild sublimate soltion (1 to 3 : 4,000) is not inappro- 
priate. Calomel is used as a dusting-powder alone or in combination 
with equal parts of bismuth and oxide of zinc. When the chancre shows 
a tendency to irritation and suppuration it is best treated, after being 
properly cleansed, with iodoform or one of its substitutes, among \Yhich 
may be mentioned iodol, aristol, europhen, and nosophen. The last prep- 



1 



PRIMARY LESION OF SYPHILIS. 219 

aration has proved very satisfactory and is especially commended. The 
mixed sore must be treated like a chancroid. 

If the lesion be complicated with phimosis the treatment should be 
conducted on the lines laid down under that heading. 

[For a differential diagnosis between chancre and chancroid see Chan- 
croid.] 



CHAPTER VII. 

CONSTITUTIONAL SYPHILIS. 
Stages of the Disease. 

Syphilis is not a continuous chain of symptoms. It is a broken 
series of outbreaks, varying in intensity, in duration, and in the length 
of the intervals between them. During these intervals the patient may 
seem perfectly well. That the poison continues active during the periods 
of latency (the early ones) is evident from the fact that syphilis has been 
acquired from the blood of a subject not at the time bearing any trace of 
syphilis upon his person ; that syphilitic women, during periods of most 
absolute latency, have brought forth syphilitic children; that trauma- 
tisms upon syphilitics, in a period of latency, often call out syphilitic 
lesions. 

Therefore it becomes impossible to state absolutely that the disease 
is naturally divided up at all. It may be one continuous malady with 
remissions, but really continuing all the time. Yet facility of descrip- 
tion, custom, and the peculiar character of the outbreaks of syphilis 
have justified its division into stages, and these stages are commonly 
known as primary, secondary, and tertiary. 

The primary stage is all that portion of the disease lying between the 
moment of infection and the time of appearance of the first general erup- 
tion with its fever and general ganglionic engorgement; it therefore in- 
cludes the initial lesion with its accompanying lymphangitis and adenitis, 
as described in the last chapter. 

The Secondary Stage. — As soon as the secondary incubation has 
passed, secondary syphilis begins. It may date as early as three weeks 
from the time of appearance of the chancre ; it generally does not com- 
mence for six weeks or two months, and may be delayed much longer, 
especially if mercury has been used in treating the primary stage. Most 
of the symptoms of this stage are superficial. They are first congestive, 
and occurring on the mucous as well as on the cutaneous expansions. 
Gradually, as time passes, the lesions become deeper seated, and finally 
the second merges so gradually into the tertiary stage that it is impossible 
to fix upon a positive boundary between them. 

The duration of secondary syphilis, like the duration of the whole 
disease, varies so greatly that it is not only impossible, but even unwise, 
to attempt to confine it within definite boundaries. In a general way, in 



. 



CONSTITUTIONAL SYPHILIS. 221 

most cases the symptoms merge into the tertiary forms during the second 
year ; but secondary lesions continue in many cases to crop out occasion- 
ally in the third year or later, intermingled with the deeper lesions of 
tertiary stage. It is not at all uncommon for a patient with a gumma- 
tous, destructive ulcer of the throat to have also upon his palm a super- 
ficial scaly patch very similar to what he may have had during the first 
year of his disease. 

And, on the other hand, but more rarely, the symptoms legitimately 
belonging to tertiary syphilis occasionally come on earlier, and appear 
among the secondary symptoms. Gummata in various situations may 
thus appear prematurely ; nodes on bones, advanced symptoms of nervous 
disease, hemiplegia, epilepsy, sometimes show themselves at the end of 
six months, and are followed by secondary symptoms, instead of appear- 
ing at their regular time about the second year or later. 

The tertiary stage commences on the boundary line of secondary 
syphilis, about the second year or sometimes considerably later, and em- 
braces everything which may happen afterward due to the disease. The 
lesions are infiltrative, gummatous, often destructive, ulcerating, and in- 
clude most of the connective-tissue parenchymatous changes and gummy 
deposits which involve the viscera. 

In inherited syphilis the symptoms of both secondary and tertiary 
stages are customarily more or less combined. The child, when born, 
often has lesions in its lungs, liver, kidneys, thymus, and spleen, with 
changes in the epiphyses of the long bones, and at the same time super- 
ficial, scaly, erythematous, papular, and excoriative patches upon its 
integument and mucous membranes. 

In acquired syphilis the whole of the tertiary stage may be absent. 
The disease not uncommonly, under judicious treatment, ceases entirely 
at the end of the secondary stage, and the patient lives for years without 
another symptom, raising healthy children, and himself to all appear- 
ances well. 

The secondary incubation period commences when the chancre appears, 
and ends when general symptoms come on. This period often is not one 
of latency, strictly speaking, since active symptoms of syphilis are usually 
present upon the patient during the whole of it, for the chancre has rarely 
healed before the first eruption comes out (unless treatment keeps it back) ; 
and even if the chancre has gone, the inguinal glands are certain to re- 
main engorged during a much longer time than the period of secondary 
incubation. 

The length of the second incubation in untreated cases varies from 
twelve days to between four and five months ; but commonly, in untreated 
cases, it lasts about six weeks. 

During the second incubation, while the organism is becoming satu- 
rated with the poison, the general health may appear flourishing, or 



222 VENEREAL. DISEASES. 

show some signs of falling off, yet there is often no positive failure of 
health until the eruptions appear, and sometimes no obvious failure even 
then. 

Symptoms Attending the General Outbreak of the Disease. 

All descriptions of syphilis refer to the symptom of fever as being 
one of the most constant accompaniments of the constitutional disease. 

It comes upon the patient unawares during the period of second incu- 
bation, and precedes the outbreak of the first eruption. It is this fever 
to which the name syphilitic is given. 

The type of the fever may be continued, remittent, or intermittent. 
It may consist of a single short outburst, or may last for days. More 
rarely, it is accompanied by great prostration, attended by headache and 
epistaxis, and assumes a type suggestive of typhoid fever. 

Its occurrence is by no means uniform. If it is looked for by aid of 
the thermometer, it will be often found ; otherwise it may not be thought 
of either by the patient or physician, excepting in a minority of cases 
when the prostration is great or the range of temperature high. 

The thermometer rarely marks higher than 102° F. in syphilitic fever ; 
104° has been pretty generally considered to be a point above which it 
does not go. 

The symptoms attending the fever are very variable. Anaemia may 
be quite marked, the pallor being due to the well-known diminution in 
the haemoglobin of the blood, first pointed out (1844) by Grassi. Gen- 
eral depression and a feeling of being sick are common complaints. Pains 
in the bones, in the joints, under the sternum, in the side and back, in 
the head, all of them worse at night, are apt to be complained of. The 
night headache is pretty constant and sometimes frightfully severe, the 
pain coming on and yielding at stated hours, often with great regularity. 

When the fever runs high and an eruption appears, the mistake 
of confounding syphilis with measles, or even with smallpox, has been 
made. 

Jaundice may come on with syphilitic fever, due to catarrh of the 
bile ducts, from engorgement of the mucous membrane, or pressure upon 
the ducts by enlarged glands. 

Pressure upon the lower third of the sternum will sometimes evoke a 
pain not otherwise complained of, and the anaemia may be great enough 
to give the soft, blowing character to the first sound of the heart. 

Syphilitic fever usually disappears soon after the general eruption 
comes out. Its own special features are so varied that its diagnosis de- 
pends upon the previous (or actual) existence of a chancre and the presence 
of evidences of general syphilis. 

During syphilitic fever, or at the beginning of general syphilis, when 



CONSTITUTIONAL SYPHILIS. 223 

there is no fever, it is common to observe other symptoms which mark 
the onset of the secondary stage. These need not be fully described here, 
since they may be found under their appropriate heads ; but, before going 
into syphilis as affecting the tissues and organs, it is well to mention them 
in outline. 

With scabs in the hair and the mottling of the skin or circumscribed 
eruptions the ganglionic pleiad in the groin still remaining, and perhaps 
the chancre being still raw, we may find that one or both epitrochlear 
glands are indolently indurated, resembling the glands in the groin, and 
certain glands in the posterior chain of the posterior cervical glands may 
be similarly affected. The glands most characteristic among these are 
those lying on the occipital bone on either side. These glands, as well as 
the glands in the groin, generally disappear, with or without treatment, 
as the disease advances, and it is not well to depend upon them to corrob- 
orate syphilis after the first few months. 

Another symptom is a generalized falling of the hair (syphilitic alo- 
pecia) . The hair thins out over the whole scalp, does not fall in patches, 
and with this there may generally be noted a tendency to a fall of hair 
from the beard and eyebrows, and more or less from the whole body in 
severe cases. This alopecia, however, is often confined to the scalp. 
When the hair falls late in syphilis, if the falling out of hair is general, 
it is due to cachexia; if it is local, it is due to a local physical lesion 
(ulcer) involving the papillse, and the hair does not generally return when 
the disease gets well, as it does after the alopecia of early syphilis. 

The throat symptoms — erythema and mucous patches — to be described 
later, are very characteristic, and should always be looked for in the out- 
break of general syphilis. 

Certain sympathetic nervous symptoms have been spoken of which 
occur more particularly in women early in syphilis — inability to distin- 
guish heat from cold, ansesthesia of certain limited areas of skin, marked 
coldness of the hands and feet, etc. 

Some patients, especially women, suffer from mental disturbances, 
such as hallucinations, delusions, and hysterical manifestations. 



CHAPTER VIIL 
THE GENERAL TREATMENT OF SYPHILIS. 

Syphilis is naturally a self-limiting malady, and its general treat- 
ment may be, and often is, left entirely to nature. Many a woman, and 
occasionally a man, gets syphilis without knowing it, and runs through 
the disease into health without any specific treatment at all. Indeed, it 
may perhaps be justly doubted whether treatment of any kind can shorten 
the duration of syphilis, for the disease will, and it does, crop out at 
remote dates after any and all kinds of treatment (less often after cer- 
tain kinds of treatment than after others), and there is no positive and 
certain test which can be applied to a person to determine whether he is, 
after treatment, free from the disease or not. 

There is no doubt whatsoever that certain drugs restrain the manifes- 
tations of syphilis and cure the symptoms. Among these the different 
preparations of mercury and of iodine undoubtedly hold the first rank ; but 
the opponents of the internal use of mercury claim that, by curing the 
earlier symptoms, the disease proper is only being suppressed, that its 
total duration is thereby prolonged, and its later symptoms rendered more 
obstin-ate and more destructive. This assumption, however, is the result 
of the heat of controversy more than of any calm recognition of facts. 

Who shall say, in a given case, how long syphilis is to last? There 
is no certain and reliable standard by which the disease may be judged 
or the quality of its virulence predicated. There is an unknown element 
in syphilis which alone can explain the endless irregularity of its forms 
and the picturesque variety of its symptoms. 

One fact about syphilis is well known; it has symptoms, and certain 
drugs will ■ keep down those symptoms ; and it is as wise and as just to 
say that the quinine which breaks tertian ague only prolongs the disease 
by suppressing the symptoms, as it is to hold that mercury prolongs 
syphilis by keeping symptoms in check. 

Moreover, the use of mercury has been shamefully abused in times 
past. Crusades have been preached against it by valiant champions of 
other and seemingly more simple methods, yet always, century after cen- 
tury, the profession clings to mercury ; and to-day it heads the list of 
specifics, as being the most efl&cient of all known drugs, in the writings 
of a great majority of the recogiaized authorities upon syphilis. The only 
question is how to use mercury so that it shall inflict the greatest possible 
harm upon the disease without injuring the patient. A solution of this 



THE GENERAL TREATMENT OF SYPHILIS. 225 

problem is what is required. The senior author has done what he could 
toward solving it. 

All sorts and varieties of other drugs — copper, gold, arsenic, sarsa- 
parilla, and various vegetable so-called blood purifiers — have been and 
are to-daj vaunted as possessing curative powers over syphilis, as have 
also the waters of numberless natural mineral springs; but no two 
authorities agree in defining the claims of these adjuvants to treatment, 
while all advocate mercury administered in one way or another. 

Finally, all sorts of cures have been tested : water cures, dry cures, 
sweating cures; cures by the grace of God (Diday) — that is, where noth- 
ing is done in mild cases beyond what is suggested by ordinary hygiene, 
the disease being left to run itself out by nature ; cures by syphilization 
and by tartarization ; and finally, by drugs, cathartics, diuretics, sudori- 
fics, tonics, mercury, iodine, etc. 

When so many methods are strongly advocated, it seems fair to sup- 
pose that the disease in question is incurable ; but, on the contrary, pa- 
tients get well, or seemingly well, under all these methods and under 
all systems of treatment. The reason of this seems to be that the dis- 
ease is self -limiting and symptoms cease to appear, in a majority of 
cases, in the long run, with treatment, without treatment, sometimes 
despite treatment. 

The aim of a rational treatment, therefore, must be: to suppress 
symptoms and prevent them from doing harm during their existence ; to 
control symptoms and prevent relapse without harming the patient; and 
so to manage the disease that it may not be contagious during its exist- 
ence (by keeping down such symptoms as yield contagious secretions), 
that the patient may be made able to marry as soon as possible and to 
produce healthy offspring, and that the symptoms of the disease during 
their progress shall be restrained from leaving unsightly scars or damag- 
ing the structure of tissues or organs. 

These ends may be more certainly attained by the judicious use of the 
preparations of mercury and iodine than by any other means ; and this 
is the reason why these drugs hold their place in medicine as antisyphi- 
litic specifics, notwithstanding the fact that the disease goes on and runs 
its full course in spite of their use, and notwithstanding the fact that 
much harm has doubtless been done with the drugs by their unskilful use. 

Sigmund and Diday about twenty years ago made strong pleas for 
what might be called the hygienic and expectant treatment of syphilis 
when mild, believing that mercury did harm in such cases and that nature 
might be safely trusted to cope with them; yet even they in all severe 
cases founded their hopes upon mercury alone. 

Zeissl, ^ in a studied essay, states that by observing the evolution of 

^ Wiener med. Zeilung, Nos. 1, 2, 3, and 4, 1879. 

15 



226 VENEREAL DISEASES. 

syphilis under the expectant treatment, he learned that the malady was 
atypical, seeming to depend, for the length of time it lasted and the 
severity of its symptoms, more upon the personal physical individuality 
of the patient than upon the treatment to which he was subjected. And 
there is a large measure of truth in this conclusion, and because of it a 
skilful advocate may justify all heresies of treatment and with equal ease 
condemn the most sound doctrine. 

Some of the symptoms of syphilis disappear under the influence of 
intercurrent disorders. Thus, Mauriac has shown' that erysipelas exer- 
cises a curative influence over the cutaneous manifestations of syphilis. 
The eruption fades, that part over which the erysipelas has travelled 
getting well promptly, while the more distant lesions are slower in 
disappearing. 

This is not more strange than the disappearance of cutaneous lesions 
not syphilitic, on the advent ,of some internal malady — tuberculous 
meningitis, typhoid fever, and others. 

The Hot Springs of Arkansas. — These springs have acquired a wide- 
spread popularity, and some estimate of their value must be given. Some 
of the best physicians at the Springs state in so many words that there 
is no more virtue in that hot water than in other water equally heated. 
The water is very hot, so that it has to be reduced before patients can 
use it for drinking or bathing purposes. It is a clear, pure water, prac- 
tically devoid of minerals, and is used upon some of the hotel tables, 
cold of course, as ordinary drinking-water. It is not exported, no one 
for a moment believing that the water, when cold, possesses any medicinal 
virtue whatsoever. Yet there is something about the heat that differs 
from the heat imparted to ordinary water by boiling it. Thus a bath 
taken in the spring water reduced to 98° F. will make the perspiration 
roll in drops from one's nose while lying in the bath — a phenomenon 
which will not occur when he takes a bath at 98° !F. in his o.wn bath-tub 
at home. Moreover, one may raise the temperature of the entire body (as 
shown by a thermometer in the mouth) by taking a foot-bath in Hot 
Springs' water; and he will fail to do this while taking a more prolouged 
foot-bath in much hotter water at home. The diuretic and diaphoretic 
qualities of the Hot Springs' water are also most marked — qualities both 
of which are lost when the water is allowed to cool. Furthermore, it is 
notorious and most obvious that one may absorb a vastly greater amount 
of mercury by inunction, the prevailing method at the Springs, than at 
home without inducing salivation ; and even more strikingly a patient who 
at home, let him drink any amount of ordinary hot water, will revolt at 
three hundred grains of iodide of potassium a day and fail to find relief 

^ "Etude clinique sur I'Influence curative de I'Erysip^le dans la Syphilis." 
Paris, 1873. * 



THE GENERAL TREATMENT OF SYPHILIS. 227 

from his severe tertiary symptoms, at the Springs, while drinking freely 
and bathing in the natural hot water, will digest one thousand grains a 
day with hardly a murmur;, and consequently will see his symptoms 
promptly disappear. 

It is this quality that gives value to the Hot Springs — a value which 
they certainly have. 

A patient with chancre and early syphilis is no better off at the Hot 
Springs than he is anywhere else. He is rather worse off, because he is 
liable to be overtreated and to be deluded into a false security because 
his symptoms disappear quickly. His relapses occur just the same, and 
his malady lasts exactly as long whether he goes to the Hot Springs or 
not. He gains nothing. His treatment can be carried on just as well 
at home, and he avoids exposure to publicity and public criticism by 
staying at home. 

It is only in the cachectic and in those whose tolerance of mercury is 
poor, or whose stomachs refuse to absorb enough iodide of potassium 
promptly to control their gummatous lesion — it is only in these cases that 
the Hot Springs lend valuable aid, and in such cases the aid is most valu- 
able — so valuable that it would be a serious loss to the community were 
the Hot Springs to disappear from the face of the earth. 

This same quality — namely, iiot directly affecting syphilis in the 
very minutest degree, but making the patient vastly more tolerant of 
mercury and iodide of potassium, which latter do the work — this same 
quality is possessed more or less by all hot springs having marked diu- 
retic and diaphoretic properties whatever be their mineral constitution 
— and by the cave at Glenwood Springs as well — they greatly aid the 
patients to take mercury and iodide of potassium freely, an aid which 
has to be invoked for emergencies, but for emergencies only. No natural 
spring so far as heard from has any specific influence over the manifes- 
tations of syphilis, except locally to stimulate the granulation of chronic 
ulcers. 

Hygienic Treatment. — The hygienic surroundings of a patient influ- 
ence his general health, and upon the maintenance of good general health 
often depends the quality of the syphilitic symptoms in a given case. 
This remark is not absolutely true — indeed, probably no remark made 
about syphilis is absolutely true. Some old men, with broken vitality, 
in the decline of life, get syphilis, and have it in the very mildest form, 
while robust youths sometimes sink away promptly under a malignant 
onset of the disease. The activity of the poison in babyhood is well 
known, and that, too, not in cases of inherited syphilis alone. Epidemics 
of vaccinal syphilis clearly prove the virulence of acquired syphilis in the 
infant. Therein there are apparently certain diathetic or constitutional 
peculiarities of the individual which influence the quality of his syphi- 
litic symptoms, and act independently of hygienic surroundings and of 



228 VENEREAL DISEASES. 

everything else. This subject has been discussed in the section on Prog- 
nosis. 

Therefore it cannot be absolutely said that hygiene, when good, will 
make syphilis mild, and when bad, will make it severe, for this is not the 
case. It is possible, however, I think, to make the following assertion 
with truth: that, other things being equal, the better the hygiene and 
dietetics the more creditably will the patient weather the storm, and the 
more certainly will his disease get well without materially damaging him. 
This assertion, of course, implies that, in addition to his hygiene and 
dietetics, the patient shall make use of intelligent therapeutics. 

The hygiene of syphilis is that of common, every-day life. We no 
longer confine patients to their beds for the treatment of syphilis, or even 
to the house. The old notion, that it is such a serious matter for a pa- 
tient taking mercury to catch cold, cannot be held in force. Surely it is 
wiser for a patient taking mercury not to catch cold, because the cold is 
likely to upset his stomach and to interfere with his treatment; but 
beyond this nothing is likely to happen, nor is it at all probable that a 
patient taking mercury in a mild, continuous way is any more likely to 
catch cold upon exposure than another under the same circumstances not 
taking mercury. Mercury may open the pores, as the popular notion is, 
for all that is known to the contrary. Mercury certainly is excreted in 
minute amounts by the skin, in the perspiration; but it means nothing to 
say that the pores are open — they undoubtedly always are open. Finally, 
to sum up, it may be confidently stated that a patient, while taking a mild, 
continuous course of mercury, may go out in the cold, the rain, and the 
storm, exactly in the same way as if he were not taking the drug, without 
being injured thereby. 

Moreover, a cold taken in the active stage of syphilis may produce 
sore throat, and this sore throat, due primarily to cold, may be the occa- 
sion of a local outcrop of mucous patches and syphilitic ulcers in the 
throat, which may continue long and greatly annoy the patient, as well 
as possibly aggravate his disease by interfering with swallowing, and 
therefore with nutrition. An accidental sore throat may produce syphi- 
litic symptoms in the throat just as smoking may, and just as a blister 
placed upon the skin, or a sulphur bath, may call out a syphilitic eruption 
upon a patient whose skin until then has remained clear. 

Probably the best precautions against taking cold are the use of 
coarse bath mittens every morning upon the dry skin of the whole body, 
when there is no general eruption; soaking the feet, upon retiring at 
night, in cold water, washing the neck and chest in cold water in the 
morning, and not wrapping up the throat tightly while out of doors — as 
well as the avoidance of wet feet and draughts. 

Cleanliness of the whole surface of the body by frequent bathing is 
very desirable during the whole continuance of the treatment. Of exer- 



THE GENERAL TREATMENT OF SYPHILIS. 229 

cise and air the patient should have an abundance. The function of the 
stomach and the intestine should be ministered to by appropriate food, 
and regularity as strict as possible should be observed in regard to meal- 
times and the hours of sleep. 

As to the kind of food to be used, no special restrictions need be put 
upon the patient. He may eat what he chooses and what he knows will 
agree with him in full quantity, in ordinary health. There is no objec- 
tion to the use of wine or beer in moderation with the meals, but any ex- 
cess in alcohol in any shape is harmful, and drinking between meals 
should not be allowed. Many individuals do very much better if they ob- 
serve total abstinence. Acids are considered harmful when mercury is 
being actively pushed — but only in such cases. When taking an ordinary 
mild, continuous course a patient may eat pickles and acid fruits — lemons 
— in all ordinary amounts without discomfort or disadvantage. When a 
patient is being crowded with mercury, acids may encourage salivation. 

Under certain circumstances the regulation of food becomes very im- 
portant, namely, when the medicine irritates the stomach so that it cannot 
be borne. The mercurials in any form, in some cases of weak digestion 
and irritable bowels, cause more or less griping and colicky pain, and the 
iodides often produce nausea and disability of the stomach. The mercury 
may be made to remain quietly in the intestine by the aid of opium, but 
it is far better to accomplish the same result, if possible, by means of a 
change of food. 

When, therefore, moderate medication, such as may be necessary to 
keep down the symptoms, is found to produce pain and diarrhoea, all 
fruit and green vegetables must be denied the patient. He should take 
but little fluid of any sort. He should eat stale bread, tender meat, rice 
and boiled milk, eggs and toast, and by the exercise of these simple pre- 
cautions he will often be able to continue his mercury and avoid opium. 
If another medicine must be given, it is well to commence with gr. x. doses 
of the subnitrate of bismuth; and if this serves to comfort the intestine, 
and keep pain and diarrhoea in check, it certainly is simpler and less apt 
to do harm than opium. The digestive disturbance will sometimes dis- 
appear when the form in which the mercury is administered is changed. 
Besides these means, it may sometimes be necessary to employ opium as 
well; but, if the opium can be avoided, it is to the patient's advantage. 

The same general precaution in regard to diet may be employed when 
the iodides disagree. The subcarbonate of bismuth may be tried instead 
of the subnitrate in these cases. 

The residence of the patient is not a matter of much importance, if 
his general health and his appetite remain fair, and his symptoms yield 
reasonable obedience to the medicines employed. Change of air, how- 
ever, is always desirable occasionally, even for persons in ordinary good 
f health, and this is the more necessary when the patient is laboring under 



230 VENEREAL DISEASES. 

a devitalizing disease. Therefore, even if the course of the malady leaves 
nothing to be wished for, it is wise, for such patients as can afford the 
time and the money, to make a change of residence for a certain period 
of time each year, in the summer if they live in town, in the winter if 
their home be rural. 

This change of air and surroundings becomes a matter of necessity in 
some cases, particularly in the later periods of the disease, if there be any 
tendency to cachexia. I have known patients, both early and late in the 
disease, who have failed to respond to medication until that medication 
has been supplemented by a change of air, when not only would the 
symptoms promptly mend, but the tone of the stomach would improve, 
and medicines which could not be taken at all without interfering with 
digestion could be borne without a murmur. This is particularly the case 
with the iodides. 

In one case in mind this effect was strongly marked. The patient had 
a node which threatened to destroy the nasal bones. He could not take 
the iodides without having his stomach totally upset, while at the same 
time the iodides produced a brilliant crop of purpura on each occasion 
when they were tried. The patient was therefore sent to the country, 
with directions to continue his medicines there. A few days sufficed. 
He bore the drug well, his purpura disappeared, his stomach regained 
its tone, the node in his nose visibly diminished in size. He returned 
to the city, thinking himself safe ; but a few days convinced him to the 
contrary : his stomach again refused food, his purpura returned, and he 
was obliged to go back to the country and to remain there until his node 
disappeared, which it promptly did. 

The advantage patients in the cachectic stage of syphilis often derive 
from visits to springs, or to cities even, for the purpose of consulting some 
special physician about their disease, is no doubt sometimes due to the 
improved hygienic effect of their surroundings. This effect in New York 
City seems to last about six weeks, after which patients become used to 
the locality and fail any longer to improve in it — from the effect of cli- 
mate alone. 

The hygiene of the mouth is of the first importance in the treatment of 
syphilis. Mouth lesions and throat lesions form some of the most obsti- 
nate features of the disease, and these lesions are less apt to be severe 
when the mouth is kept clean and free from the contact of irritants. 
At the very beginning of syphilis, therefore, before the mercurial course 
is commenced, the patient should be sent to a dentist to have his teeth 
put in thorough order. All the tartar should be carefully scraped away 
from the necks of the teeth, and all old stumps extracted, and sharp 
projecting angles of teeth likely to come into contact with the tongue filed 
off. The patient should be instructed that he will do well to visit the 
dentist regularly every six months if the tartar tends to re-accumulate 



THE GENERAL TREATMENT OF SYPHILIS. 231 

quickly, as it does in some cases. During the whole of the treatment a 
very soft tooth brush should be used, for the stiff bristles of a hard brush 
cut and injure the gums, and make them more likely to become irritated 
under the influence of mercury than if a soft brush be used. Any tooth 
wash employed, or tooth powder, should be strongly alkaline and a little 
astringent. A good, simple tooth wash is made by putting half a tea- 
spoonful or more of bicarbonate of soda into a glass of water, and adding 
a teaspoonful of tincture of myrrh. Ordinary white castile soap makes a 
good and simple tooth paste, and the mouth may be washed out afterward 
with some alum and water, or some tincture of krameria (3 i. ) in aqua 
gaultherise ( ^ iv.). 

Smoking should be forbidden when mouth lesions persist and are 
troublesome. In some the mucous membranes are but little if at all in- 
volved, and such may smoke if they wish to, or even chew tobacco with 
impunity — it is totally a personal question. 

A pipe is a dangerous thing for a patient with syphilis to use, for he 
runs the risk of infecting any friend who might use it, the secretions of 
mucous patches and syphilitic ulcers in the mouth being particularly con- 
tagious. 

The hygiene of the genitals and of the anus is also important. These 
parts in both sexes should be kept scrupulously clean and dry, otherwise 
mucous patches and condylomata, excoriations and ulcerations, may be 
looked for. Should there be any tendency to moisture about these parts 
externally, they may be dusted with dry powders, talcum powder or bis- 
muth, with or without a little calomel, after proper cleansing. It is 
well, in some cases, to have the patient wash the anus with soap and 
water after each action of the bowels. The umbilicus, also, in fat peo- 
ple, and the skin under the breasts in fat women, require frequent wash- 
ing, drying, and dusting to preserve the parts in good condition during 
the eruptive period. 

Medicines used in syphilitic cases, to keep up the general health or 
regulate the functions, come more justly under the head of hygiene than 
of specific medication. 

All tonics find a fair field for their exercise in syphilitic subjects, and 
do good — not, perhaps, in curing the disease, but by holding the patient 
up while it works out its periods. The effect of mercury, when given in 
small doses for a long or for a short time, is undoubtedly tonic, as has 
been shown ;^ but it is not at all on account of this tonic action that mer- 
cury given in minute doses eliminates the syphilitic poison. Other drugs 
are far more tonic in their action, but, having no specific power over the 
symptoms of syphilis, they directly modify the disease but little, if at 
all. The only advantage claimed for the long-continued use of mercury 

'"The Effect of Small Doses of Mercury," etc., Am. Journ. Med. Sci., January, 
1876. 



232 VENEREAL DISEASES. 

in minute doses is that, while acting in minute doses as a specific, it has 
the great advantage to the patient of being at the same time tonic. 

Now, the ordinary tonics — such as the long list of vegetable bitters, 
the quinine group, iron, and analogous drugs, together with cod-liver oil 
and similar blood-formers — all of these serve a good part in the treat- 
ment of syphilis, just as other hygienic means do. If employed with 
intelligence and judiciously changed, they in a measure take the place of 
change of air and selection of food in those cases in which lack of money 
will not allow the patient to alter his food or to get a change of air. 
Cod-liver oil is a particularly useful adjuvant to treatment in those cases 
in which the blood-making powers are- defective, while the ability to 
digest fat remains. 

In persons who lack blood, yet in whom the stomach refuses to accept 
or to assimilate so concentrated a food as cod-liver oil, an excellent substi- 
tute is found in kumyss, buttermilk, zoolak, matzoon. 

Specific Treatment. 

The specific treatment of syphilis is a treatment of the disease by 
those drugs which are known commonly to control the symptoms in an 
immediate manner. These drugs are the preparations of mercury and of 
iodine. The latter are found to exercise much less influence over the 
symptoms of early sj^philis than mercury does ; but, they possess a con- 
trolling power over many of the later manifestations of the disease, par- 
ticularly those dependent upon gummatous deposit, no matter in what 
tissue such deposit occurs. 

Mercury, on the other hand, has undoubted value in all stages of 
syphilis and over all its lesions, but less control over gummatous deposit 
than over other lesions. While sometimes it will (in form of fumigation) 
influence a gummatous lesion (ulcer, for example) more positively and 
more promptly than the iodides, yet, as a rule, it cannot be relied upon 
for this purpose. The iodides, in such cases, serve an excellent part to 
supplement the action of mercury. In treating a gumma, the object is 
to dissipate the deposit as promptly as possible, so as to save the tissues 
involved from damage by pressure, or by disintegration when they are in- 
cluded in the gummatous mass; and this the iodides do speedily if vig- 
orously pushed and well borne by the stomach, while the mercurials will 
often fail to do it. 

The iodides, on the other hand, have little or no power to prevent 
relapse ; and, when they have done all their work, mercury often has to 
be called in to clinch the cure, and to prevent a return of the symptoms. 
Thus the two specifics support each other. 

The senior author has demonstrated in two essays* that the red cells of 

' "Effect of Small Doses of Mercury, "etc., Am. Journ. of the Med. Sci., January, 
1876, and "The Treatment of Syphilis," Philadelphia Med. Congress, 1876. 



THE GENERAL. TREATMENT OF SYPHILIS. 233 

the blood are increased in number when mercury is used continuously in 
a certain way. Hence it is a tonic when so used, in spite of the protest 
from Germany that it does not act (as to the elimination of urea, the bod- 
ily temperature, etc.) just like iron, and in spite of the protest from 
^ew York that the haemoglobin should have been quantitatively esti- 
mated also. Those interested in following the study of the blood and 
the course of argument derived from other facts which prove that mercury 
in minute doses long continued is a tonic, while in large doses it is atonic, 
diminishing the number of the red cells in the blood, are referred to the 
two papers in question. There it will be found to be demonstrated that 
mercury, properly used for a number of years in succession, cannot do any 
harm to a patient, while it certainly in most cases controls his symp- 
toms in a greater or less degree. The years which have passed since the 
appearance of those papers have only served to strengthen the convictions 
as to the correctness of the conclusions there reached. The only modifi- 
cation made has been to increase somewhat the dose of mercury for con- 
tinuous use. 

Mouth symptoms during this course are generally more obstinate than 
any others, but the little scaly patches upon the tongue and lips may 
often be looked upon more as an evidence of local irritation in a person 
once syphilitic than anything else, and may often be guccesfully treated 
locally without making any change in the internal dose which the patient 
may be taking at the time. 

The coup-sur-coup plan of giving mercury is unsatisfactory, judged by 
the results in the way of relapses seen in patients who have so taken the 
drug at competent hands. The plan known as Fournier's treatment, 
which consists in the interrupted use of mercury in mild dose (a gentle 
coup-sur-coup method), with stated definite intervals in which no treat- 
ment is used, seems to rest upon no foundation stronger than theory, 
since syphilis, a malady of interruptions undoubtedly, has its interruptions 
at indefinite and irregular intervals. Notwithstanding that intervals of 
latency in the malady exist, periods of apparent immunity from the dis- 
ease, yet there is nothing to prove that the patient is free from the poi- 
son during those intervals, but everything to show that he is still suffer- 
ing. The cauterisatio provocatoria of Tarnowsky is founded upon this 
assumption. A blister or a local irritant (vaccination) will sometimes 
make latent syphilis active — a woman seemingly perfectly healthy will 
often produce a syphilitic child. What conclusion can therefore be 
reached except that syphilis is a mild, contiauous disease, with periods of 
passive latency and period of active outbreak ; and what treatment, there- 
fore, recommends itself more to common sense than a mild, long-continued, 
uninterrupted treatment by a specific known to have power over the symp- 
toms, with an increase in the quantity of that specific during the periods 
of outbreak? 



234 VENEREAL DISEASES. 

And this becomes especially apparent when it can be shown, as has 
been done, that the continuous use of the mild specific acts as a general 
tonic (as well as performing its work as a specific) during the whole 
period of its administration. 

The method indeed has all the advantage of the coup-sur-coup meth- 
od, but its coup is mild. It hurts only the disease, never the patient. 
The '' blow " falls only during the period of active outbreak of the dis- 
ease, while the general treatment has the further advantage of acting con- 
tinuously as a specific in eliminating the poison of syphilis and prevent- 
ing it from causing outbreaks in the way of serious symptoms. This 
treatment constantly tends to keep the disease down, and to keep the 
patient up. It does not cure the disease so much as it conducts the 
patient safely through the periods of the disease. It does not prevent 
relapse later in life with certainty, for occasional cases of such relapse do 
certainly occur ; but it insures one more positively against relapse than 
any other form of treatment — at least, than any other with which the 
authors are familiar. 

Salivation is undoubtedly harmful. Much of the odium which rests 
upon mercury is due to the harm it has done to the mouths and stomachs 
of patients by salivation. In the days when it was considered that the pa- 
tient never had arrived at his proper dose of mercury until he was caused 
to spit at least a pint in twenty-four hours, how much damage must have 
been done, and how justly has mercury paid the penalty by falling into 
popular disrepute! 

That salivation becomes necessary in desperate conditions of disease 
late in syphilis is certain; but surely it has no value as a means of 
general treatment, and can never happen to a patient early in the disease 
without doing him positive harm. 

The time when the general treatment of syphilis shall be commenced 
is a question of great importance. Unquestionably it should be com- 
menced as soon as the disease is diagnosticated; but the difficulty is that 
diagnosis, before the eruptive stage — positively absolute diagnosis — is 
rarely possible without confrontation, and even then there is a chance for 
error found in the possibility of infection through another source, or in 
mediate contagion. 

Practically, therefore, the treatment should not be commenced until 
the first general symptoms of syphilis appear ; the chancre with the 
accompanying glandular engorgement is not enough to go by. If treat- 
ment be commenced while any doubt exists, that doubt remains, and the 
patient may continue in doubt for the rest of his life, to his great discom- 
fort ; therefore, although he may demand treatment, and beg for it when 
he has a chancre, the surgeon will do him a kindness by refusing internal 
specific measures until the first general symptoms begin to appear. 

In the rare cases in which diagnosis can be positively made, without 



THE GENERAL TREATMENT OF SYPHILIS. 235 

the chance- for the least possible doubt — as, for instance, when a husband 
poisons his wife or his child — treatment may and should be commenced 
at once without waiting for general symptoms ; otherwise it is safer for 
all parties to wait. The patient^ s mind may be satisfied, meantime, by 
cutting out his chancre, and he may be medicated, to his advantage doubt- 
less, with tonics of all kinds ; but mercury should be denied him. 

Tonic Treatment by Mercury. — The method about to be described is 
called the tonic treatment of syphilis, to distinguish it from other meth- 
ods. It is tonic, and therefore the term is correct ; but it does not cure 
syphilis because it is tonic. It cures the symptoms because it is a spe- 
cific, and the tonic action is only an accidental one found to attach to the 
method. Even if it were not tonic, it would be proper to use mercury in 
the treatment of syphilis ; and indeed, mercury often is given, and prop- 
erly given, in such a way as to be a specific devoid of tonic properties, in 
that it is used in large doses — doses which have been shown by blood 
examinations to be anything but tonic. When, however, the specific 
medicine can be used so as to be at the same time a tonic, a step in ad- 
vance over other methods is taken, and that is the reason why this 
method is called the "tonic treatment of syphilis." 

The idea of this treatment is best carried out by using the same drug 
continuously in varying doses. If the preparation has to be changed and 
great accuracy is aimed at, it is necessary to make a new set of tests in 
order to find the tonic dose. The preparation which we have used the 
most is the protoiodide of mercury put up in France by Garnier et 
Lamoureux in the form of sugar-coated granules, containing exactly 1 
cgm. each (i of a grain).' The advantages of this preparation are 
that it does not change by climate; the protoiodide remains fresh 
inside the sugar coating, and the latter, being thin over the small gran- 
ules, always dissolves in the stomach readily ; the preparation is a solid 
one and easy to carry around, and to take without causing comment. 
The protoiodide has no special value over any other mercurial. The 
yellow iodide may be used — except that it is hard to find the tonic dose 
unless tablets of gr. -g^ - -J^, or smaller are used — because the pure yel- 
low iodide causes colicky pain to many persons even in very small dose. 

^ There is a spurious granule sold which resembles the French granule outside, 
but if cut open discloses a nucleus of white sugar, which the true granule does not 
possess. This spurious article is a little stronger than the imported. It seems to 
contain more yellow iodide and less green. The true granule is anything but a pure 
drug. It contains the chemically pure yellow protoiodide, the impure green iodide, 
specks of red biniodide and globules of metallic mercury with a little free iodine 
under the sugar coating. It is not because the granule is a pure article that it is 
popular, but because it is uniformly impure, at least so its effects seem to prove, aDd 
it is weak, so weak that some patients do not seem to feel them at all — taking them 
in large numbers very freely. But on the other hand they rarely salivate and do not 
cause much abdominal pain and they are not dangerous for the patient to handle. 



236 VENEREAL DISEASES. 

Small pills of the tannate of mercury, of gray powder, of blue mass, of 
bichloride may be used equally well, whichever form the physician is 
most accustomed to handle — always remembering that the individual pill 
or pellet must be a minute dose, if this form of treatment is to be strictly 
carried out. If the gray powder (mercury with chalk) is chosen a tablet 
of one-third or one-half a grain should be used in finding the tonic dose. 

The blue mass pill with iron is a good one, the granule being made up 
of a quarter of a grain each of mercurial mass and of dried sulphate of 
iron — until the full dose and the tonic dose shall have been determined — 
or the bichloride of mercury may be used in tincture of the sesquichloride 
of iron ; the dose being so regulated that one-fiftieth, or perhaps better, 
one-hundredth part of a grain of the bichloride shall be the standard dose 
until the tonic dose has been ascertained. 

In short, any preparation or combination of mercury may be used, 
provided it does not contain opium, the addition of which would make it 
impossible to decide accurately what the tonic dose is. The standard 
dose must be a minute one. 

The idea that the newer preparations of mercury are better than the 
old cannot be maintained, and no extra assistance is to be expected from 
such novelties as the carbolate of mercury, the thymolate, the benzoate, 
the formamide, the glycocoll, the alanate, and their kind. 

To bring a patient under the tonic treatment, if there be time, the 
following is the best course : Let him take one standard dose of mercurial 
(one granule of the protoiodide, for example) after each meal for two or 
three days. On the fourth day one extra standard dose is added at 
the midday meal ; now four standard doses (granules) are taken daily, 
and this is to be continued for three days. 

On the succeeding fourth day another standard dose is added, the five 
daily standard doses being taken two m the morning, one at noon, and 
two at night. On the next following fourth day, always counting from 
the last fourth day, another dose is added, two standard doses being now 
taken after each meal — six (granules) a day. 

In this way the amount of mercurial given is gradually increased, 
while the patient uses bland food in moderate quantity and regulates his 
habits as far as may be, and the dose is slowly increased every third or 
fourth day, or even every second day, if the patient be pushed for time 
and the presence of an eruption makes haste an object, until the irritat- 
ing or the poisonous action of the drug begins to manifest itself. 

If in any given case the symptoms are so pressing that there is not 
time to get the patient quietly under this treatment, there is no objection 
to treating him by any of the older methods until his symptoms abate. 
He may be rapidly brought under the mild influence of mercury until the 
drug shows faintly along the edge of the gums, either by inunction, by 
daily fumigations, or by corrosive chloride in tincture of bark, taken 



THE GENERAL TREATMENT OF SYPHILIS. ^37 

diluted, after meals; and when finally the urgent symptom has fairly 
declined, all medication may be suspended for a week or more, and then 
under less pressure the mercurial course may be instituted as directed 
above. 

One advantage of the French protoiodide granules, which was not 
alluded to above in the list of its virtues, is that, although it does not 
gripe when given in small quantities, yet it does show its irritating 
effects, usually upon the intestine, before it produces any trouble in the 
mouth. This is not always the case, but it is the rule; consequently, 
during this course of granules, diarrhoea and griping pain are to be 
watched for. A slight looseness of the bowels is unimportant. Such a 
looseness often comes on during the early days of the course; but, by 
holding the drug at the same dose, it subsides, and then the doses may 
be increased as before. 

When a dose of six to nine, or even twelve granules a day in some 
cases, has been reached, it will produce a very positive attack of diar- 
rhoea, with pain in the intestines ; and occasionally at the same time the 
breath will begin to have the mercurial fetor, and the livid line will 
begin to show faintly along the edge of the gums at the necks of the 
teeth, while the teeth themselves become a little sensitive on being 
snapped sharply together, and the saliva flows more freely. These latter 
symptoms are generally not much marked with the protoiodide, and they 
may be absent entirely while the griping and diarrhoea are quite positive, 
and this feature is an advantage in favor of the protoiodide. 

When either of these sets of symptoms occurs, the patient has reached 
his limit. He is taking what is called his " full dose " — a dose which he 
may continue to take with the aid of selected food and a little opium, and 
may indeed, in most cases, continue to take without becoming salivated. 
This dose is anything but tonic. If it be continued, the patient surely 
suffers in time, both in the stomach and in the quality of his blood, while 
his strength and physical powers are diminished by it. This " full dose," 
therefore, is to be used only in case of necessity. It is specific, and pos- 
sesses fully the antagonistic influence to syphilis which the mercurials 
enjoy; and the patient may take this dose for a considerable period with- 
out injury, if his symptoms require it, with the aid of a little opium to 
give him comfort, or preferably without opium, by changing his food, 
drinking boiled milk, and eating rice. 

This "full dose," the size of which varies greatly in different individ- 
uals, may be maintained until the activity of any existing symptoms 
declines, and then it should be dropped and the " tonic dose " of mercury 
substituted. 

One-half of the " full dose " is a " tonic dose, " and may be continued 
steadily during several years without injury to the patient; if anything, 
apparently rather to his advantage, for he feels well under it in most 



238 VENEREAL DISEASES. 

cases, he eats well, his functions go on perfectly, and his blood is richer 
in red corpuscles than it was before. The condition is an unnatural one, 
however. ^Nature is being outraged by the constant use of a foreign sub' 
stance, which is allowable only in order that it may counteract another 
foreign substance — the poison of syphilis — and the less of the drug that 
can be used with safety to the patient the better. Therefore it is 
sometimes as well to employ as a continuous dose a quantity somewhat 
smaller than the regular tonic dose — a quantity, for instance, equal to 
one-third instead of one-half of the " full dose " in the second six months 
of the disease when the symptoms are well under control. This dose is 
also tonic, and with it one may persist without interruption, for a long 
period of time, in the endeavor to eliminate the syphilitic poison gently, 
and to keep its explosive outbreaks within reasonable limits. The idea 
of the tonic dose is that it shall be continued daily, year in and year out, 
for, in round numbers, about two years for mild cases and longer for se- 
vere ones — alterations, of course, being occasionally made meantime, ac- 
cording to the varied necessity of the different cases. 

During the existence of all ordinary moderate symptoms, isolated 
patches of eruption, disappearing general eruptions, mucous patches, etc., 
the tonic dose may be maintained unvaried, or slightly increased, accord- 
ing to the surgeon's judgment, while local measures are brought to bear 
upon the local lesions. If more severe symptoms come on at any time, 
the tonic dose may be immediately increased to the full dose, already 
ascertained ; and after the full dose shall have done its work, it in turn 
may be again dropped to be replaced by the tonic dose. In these emer- 
gencies, instead of increasing up to the full dose, the tonic dose may be 
maintained, and inunction or fumigation or one of the other internal mer- 
curial preparations in full dosage resorted to until the emergency shall 
have passed. 

These simple directions meet the wants of most cases until some ter- 
tiary symptom arrives — if, indeed, any tertiary symptoms come on at all, 
for they may be escaped. Tertiary symptoms call for a variation in the 
general treatment. The mercury may be dropped entirely, one of the 
iodides being substituted if the lesion be purely gummatous ; or the mixed 
treatment may be called for according to the symptom. Under the heads 
of the various symptoms, it will be indicated which of the special forms 
of treatment is required. When the mixed treatment is indicated, one of 
the best combinations is the biniodide of mercury in a solution of the 
iodide of potassium. 

After the mixed treatment or the iodides alone shall have accomplished 
what was expected of them, it is well that the patient should return again 
to his tonic dose of the granules, and continue them until it is thought 
best to stop all treatment. 

In case of any intercurrent malady not syphilitic in nature coming on 



THE GENERAL TREATMENT OF SYPHILIS. 239 

during a long mercurial course, the latter may be stopped at once and 
resumed when the intercurrent malady has passed away. The mercury 
should be stopped also during any attack of acute indigestion, diarrhoea, 
and the like. • 

A special method of giving mercury internally is the plan known as 
Trousseau's which is worthy of note. By this plan minute doses of calo- 
mel, anywhere from gr. ^L to -^-^, are given hourly or at short intervals, 
with great effect in some cases in overcoming the intense headache of 
early syphilis, and for the purpose of rapidly bringing a patient under the 
full influence of mercury. One-tenth of a grain hourly will show in the 
mouth, in the case of some patients, within twenty-four hours, and will 
often purge. 

The time at which a tonic course of the mercurial specific may be 
stopped is subject to variation. About two and one-half years is a full 
course for most people, while two years answers well enough in some cases. 
Six months of entire immunity from symptoms, at the very least, or, better 
still, a year's freedom from evidences of the disease, is desirable before 
the tonic treatment is stopped. In some cases in which smoking is per- 
sisted in, an occasional scaly patch on the side or tip of the tongue, or in- 
side the lips or cheeks, need not be regarded as a sj^mptom serious enough 
to make the six months' test invalid. It is better that no symptom what- 
soever suggesting syphilis should have occurred ; but it becomes a matter 
of special judgment in some cases whether the persistence of these mild 
mouth lesions, for cause (smoking), may not be disregarded, provided there 
is and has been nothing else about the patient for a long time to suggest 
the persistence of the existence of syphilis. Occasionally, non-syphilitio 
patients are found in whom smoking will produce erosions and scaly 
patches within the mouth absolutely identical with the lesions found in 
syphilis. Should such a patient get the disease, it is not fair to let his 
constitutional peculiarities be ascribed to a syphilitic cause. 

If relapses occur after the cessation of treatment, they must be man- 
aged according to their necessities, generally best by the mixed treatment ; 
and theuj^ finally, a tonic mercurial course may be instituted for a few 
months, more or less, according to the judgment of the surgeon, and pro- 
portionate to the intensity of the relapse and its obstinacy. 

Many patients will not follow continuously the strict course which has 
been detailed ; but many others do follow it conscientiously, the more read- 
ily as they are intelligent and have the nature of the disease explained to 
them, together with the theory of the treatment. 

Mercurial Fumigation. — Before making use of the standard dose, in 
order to find the full dose and the tonic dose in a particular case ; or, 
after the tonic dose has been ascertained and when it is desirable suddenly 
to increase the mercurial influence in order to counteract some tendency 
to activity on the part of the syphilitic symptoms — instead of putting the 



240 VENEREAL DISEASES. 

patient upon his full dose of mercury, lie may be retained at the tonic 
dose, and the mild but certain influence of mercurial fumigation brought 
to bear upon him. 

Mercury in vapor acts very promptly and very kindly. The obstacles 
to its extended use are the difficulty of its apjplication, the time required 
to give a bath, the impossibility of using it secretly at home (for syphi- 
litic patients are always shy of being discovered while taking medicine) ,- 
and the expense if the baths are taken in an outside establishment. 

The value of the vapor, however, is so considerable in many cases 
that its use for emergencies should be placed within the reach of all. In 
many ulcerated and pustular lesions, and in cases in which persistent and 
chronic relapse occurs in a patient with irritable stomach and general de- 
bility, the vapor bath renders invaluable service. When pushed too far, 
mercurial vapor may cause salivation or diarrhoea, but it rarely does so 
when watched; a sense of weakness, with general depression, attended 
by more or less trembling (perhaps positive mercurial tremor), is one of 
the more common indications that the baths are being pushed too rapidly. 

In a regular mercurial bathing establishment, the patient sits naked 
in a box, sometimes with the head in (if the fumes are not disagreeable 
and do not induce coughing), sometimes with the head out. A little 
steam is let into the chamber, the temperature is raised to 90° F. or 
thereabouts, and when the body is damp and warm the mercurial to be 
used is volatilized, and, permeating the chamber, settles upon the moist 
skin, where it becomes precipitated — changed probably into the bichlo- 
ride by contact with the perspiration, and as such absorbed. If the head 
is in the fumigating chamber, a certain amount of the vapor is directly 
absorbed by the lungs. 

Fifteen to twenty minutes is ample time for such a bath, which 
should be terminated sooner if the patient grows faint. The best form of 
mercurial for the bath I believe to be the black oxide, in a dose for vola- 
tilization at first of one drachm, afterward of two drachms. Calomel is 
often used, and the sulphuret of mercury in doses of 3 i. ; but both of 
these substances irritate the lungs of some patients and may induce vio- 
lent coughing. When they are used, therefore, the head should be kept 
outside the fumigating chamber. 

Twice a week is generally often enough to repeat the bath. In some 
cases, where they are well borne, I have repeated them daily for a time, 
watching the patient carefully for the effect of mercury. 

After the bath the patient should wrap himself up in a warm blanket, 
and rest quietly for an hour or more, until he has become thoroughly dry 
without the use of a towel. 

Domestic Vapor Baths. — The form of bath above described is a good 
one, but it is an expensive luxury, and not to be obtained at all by pa- 
tients in the country. Under circumstances calling for a bath, in which 



THE GENERAL TREATMENT OF SYPHILIS. 



241 



the bathing establishment may not be suitable, an excellent substitute, an- 
swering all purposes, may be taken by the patient in his own house at a 
merely nominal cost. The appropriate essentials for such a bath are : an 
alcohol lamp with one or two good burners, and a piece of tin bent into 
the form of a table (Fig. 85), of such height that the flame will spread 
itself evenly upon the under surface of the tin. The figure represents 
the flames of the lamp as being by far too small. We have found upon 




Fig. 85. 



such a table that one good flame of a spirit lamp will volatilize half a 
drachm of calomel in four and one-half minutes, and the same amount 
of cinnabar in six minutes. One flame is therefore ample, and it need not 
be a very large flame if the sheet of tin be reasonably thin. 

Both calomel and cinnabar volatilize quite easily by this method; the 
oxides require more heat and more time. Gray powder may also be used. 
Both calomel and cinnabar (and especially the latter) may cause coughing, 
but generally the bath can be so managed that the patient is not materi- 
ally discomforted by it. If cinnabar be used, the patient may keep his 
head out, and retire into another room immediately after the bath. On 
the whole calomel is to be preferred in this form of bath, commencing by 
volatilizing a powder of twenty grains, and working up to a drachm. 

The simple method of taking the bath is as follows: the patient 
sits naked on a cane-bottomed chair, holding close around his neck, 
under his chin, a couple of blankets, which may be pinned in place so 
as to envelop the patient and the whole chair down to the floor. Under 
the blanket is placed the little tin table beneath the chair, with its 
spirit lamp unlighted, the dose of calomel lying on top of the tin table. 
Under the chair, also, is placed a pan of hot water. 

The patient sits quietly over the hot water until his skin has become 
warmed up and slightly moist, then he stoops down, lights a match, lifts 
the edge of the blanket, and lights the spirit lamp. He may leave this 
light burning until the bath is finished if he desires, or he may extin- 
guish it in five or ten minutes, according to the amount of calomel to be 
volatilized and the degree of heat he experiences. He then sits quietly 
for perhaps ten minutes longer in the fumes, occasionally opening the 
16 



242 VENEREAL DISEASES. 

front of the blankets to breathe a whiff, if the vapor does not irritate the 
air passages. He now wraps himself up in the inside blanket in which 
he has taken his bath, and remains so wrapped, lying down until he has 
cooled off, after which, without using a towel, he goes to bed. In the 
morning he may take a soap and warm-water bath. 

The effects of mercurial vapor by inhalation may be obtained when a 
patient is unable to leave his bed by volatilizing calomel or cinnabar near 
his nose upon a sheet of tin, or even upon a hot brick. Inhalations of 
this sort are of incalculable value in some cases of mouth and throat 
lesions, when the patient can make the inhalations without coughing, 
which he generally can do if they are commenced mildly and often re- 
peated, minute quantities of mercury being volatilized at a time. 

Mercurial Inunctions. — Inunction is the best method of introducing 
mercury into the bodies of infants, and many believe that it is the best 
method in the adult. The main objections to it are that it is dirty, and 
so irritates the integument in some cases that it cannot be used for any 
great length of time. When it agrees it is an excellent method, espe- 
cially to use in conjunction with the tonic internal treatment, to meet such 
emergencies as call for an increase in the amount of the mercurial em- 
ployed. It is as good a method as that by fumigation for sparing the 
stomach, and is very useful in those cases in which that organ must be 
restricted to its natural function, the digestion of food. 

There are many methods by which mercury may be introduced through 
the skin into the blood. Ordinarily the process is one of friction ; and 
the patient may do the rubbing himself with his own bare hand or it 
is done by a professional rubber, who sometimes wears gloves. 

The amount of absorption which takes place by the skin is very varia- 
ble in different individuals. A prompt effect is produced in some 
patients, a very slow effect in others; consequently, when the course 
must be long or the dose at all accurate, this method is obviously inap- 
propriate. Moreover, skins differ materially in their irritability upon the 
contact of mercurial preparations. Some patients will wear a patch of 
mercurial ointment bound upon the skin for weeks without showing any 
local redness of the skin, while in others each inunction is followed by 
local redness and itching, and a persistence of the application by an out- 
crop of the so-called mercurial eczema which distresses the patient consid- 
erably by its itching, and is, relatively, quite chronic in character and 
slow to disappear. 

In the friction method of inunction two preparations are in use : mer- 
curial ointment and mercurial vasogen. Of the two the mercurial oint- 
ment is cheap, most easily procured, and generally preferred. It gives 
satisfaction, and the common ointment if freshly made is perfectly relia- 
ble. There are many special preparations which are perfectly good, 
doubtless better than the common ointment, but the latter if fresh serves 



THE GENERAL TREATMENT OF SYPHILIS. 243 

all purposes. Among the better preparations may be mentioned steril- 
ized ointment put up in gelatin capsules, two and a half and five grams 
in a capsule, and ointments made with lanolin — to facilitate absorption. 
The mercurial vasogen is a new proprietary preparation made in varying 
percentages, and alleged to be capable of quick absorption. A moderate 
acquaintance with it seems to justify the claim. It is put up in capsules, 
33 and 50 per cent strong, two and three grams each, one of which is 
to be rubbed in by the patient each day. If it really has unusual merit 
it will remain; otherwise it will shortly follow the oleates of mercury 
and be forgotten. 

When mercurial ointment is to be rubbed in, from half a drachm to a 
drachm is a dose, to be used once daily, preferably at night. The skin to 
be anointed should be thin, for the absorption of mercurial ointment is 
not active; therefore, the flexures of the various joints are usually chosen, 
although any part of the integument will answer. The lateral abdominal 
regions when not hairy are suitable regions and convenient for the pa- 
tient. 

The portion chosen for inunction is to be slowly and firmly rubbed 
with the ointment by means of the bare fingers or the whole hand, for 
something like twenty minutes or half an hour. The task is laborious if 
properly done. The vasogen preparation is said to require a shorter 
period to obtain absorption. After rubbing the ointment in as thoroughly 
as possible, the part may be bound up in dry flannel and left for twenty- 
four hours, when it should be carefully washed with soap and warm 
water, and another friction performed upon another portion of the in- 
tegument. 

The best inunction method when conducted by a masseur is the fol- 
lowing; it is practically what is done at the Hot Springs: The patient 
straddles a chair, leaning his arms and chin upon the back of the chair. 
He is in a warm room, naked from the waist upward. The rubber taking 
one-eighth, one-sixth, sometimes one-quarter of an ounce of mercurial 
ointment, rubs it broadly over the whole back with a long sweeping, 
circular motion, and in this way going round and round, rubs the oint- 
ment thoroughly into the pores of the skin for about twenty minutes. 
The patient now puts on a thin gauze undershirt, his mercurial shirt, 
which he wears through the entire course, and goes about his business. 
On the following day, about two hours before the time for his second 
rubbing, his attendant gives him a warm soap and water bath, thoroughly 
cleansing the back. Then the skin is rubbed down with alcohol and 
clean underclothing put on, the skin being allowed to rest for about two 
hours. Then another inunction is given and the original mercurial shirt 
again put on. 

Teale's method of inunction, as it is called, consists in binding upon 
an arm or a leg a piece of bandage (or flannel cloth), upon which mercu- 



244 VENEREAL DISEASES. 

rial ointment has been thickly smeared. The bandage is kept in place at 
discretion, the surface of the skin beneath it being inspected daily, and 
the bandage removed and placed elsewhere when the skin begins to show 
any signs of redness, or the patient complains of local itching. By this 
means there is a continuous action of the mercury upon the skin day and 
night until the ointment dries up, when it must be freshened with oil or 
a new plaster applied. 

This method is mild and continuous in its action, and with certain 
skins works admirably. 

Hypodermatic Treatment. — The only other method of introducing 
mercury into the body which is worthy of consideration is that by intra- 
muscular injection, and when prompt effect is aimed at, one that shall be 
lasting and searching, this method is perhaps the best of all. We keep 
it constantly in mind for emergencies. The objections to it are, that 
it is often painful, may possibly suppurate, but out of several thousand 
injections made by the authors only two abscesses are of record; and, it 
must be borne in mind, an occasional fatal issue has been recorded after 
intra-muscular mercurial injection, due to venous thrombosis at the seat of 
puncture and pulmonary embolic infarction. The authors have never en- 
countered a case, but such cases have occurred at very long intervals in 
the best hands. 

The preparation used for hypodermatic medication is either a soluble 
or insoluble mercurial. The soluble preparations may be represented by 
the bichloride of mercury, the insoluble by the mild chloride or calomel. 
The objections to the bichloride are that it irritates sharply and like all 
the soluble preparations, being eliminated rapidly, must be employed at 
too frequent intervals. Calomel has been abandoned on account of its 
proneness to produce abscess. 

The preparation we have adopted and used constantly for many years 
is an insoluble one, the salicylate of mercury. It is prepared by mixing 
twenty-four grains in one ounce of sterilized benzoinol. The salicylate 
precipitates and must be mechanically mixed by violently shaking the 
bottle each time, and an extra large hypodermatic needle must be em- 
ployed — one and one-quarter inches long and with large calibre, that it may 
escape clogging with the insoluble particles. We use a syringe with an 
asbestos piston, which may be boiled and kept surgically clean. The injec- 
tion is to be made in th© upper and outer part of the buttock, the needle 
being plunged in its entire length and the fluid injected slowly. The in- 
jection must be made aseptically and the little puncture closed with a bit 
of adhesive plaster. We use thirty minims of this mixture usually at one 
injection, one and one-half grains salicylate of mercury, twice a week, later 
once a week. The effect is often amazingly prompt and lasting, and so 
obvious that patients soon learn to put up with the discomforts of the 
course rather than forego the advantages. In the late patches of scaling 



THE GENERAL TREATMENT OF SYPHILIS. 245 

palmar and plantar syphilide, so obstinate to almost all forms of internal 
medication, these injections work wonders. 

The direct local influence of mercury is proven by subcutaneous injec- 
tion of the drug, since it is found that when a patch of eruption is in- 
jected, it gets well, while a similar patch, more or less distantly situated, 
is not modified by the general effect upon the system of the small 
amount of mercury employed. 

Salivation. — In a properly regulated treatment salivation should never 
occur. In ascertaining what the " full dose " of mercury is in a given 
case, the gums may be touched, as the expression is ; but this condition 
cannot fairly be called salivation, although it is the first stage of it. In 
maintaining the full dose, the mouth is kept constantly in a condition of 
mild irritation, and necessarily so, in some instances, when the symp- 
toms are severe. Under these circumstances, especially if it seems prob- 
able that the full dose will have to be maintained for a considerable 
period, certain precautions should be taken with the mouth in order to 
allow the mercury full chance without in any way encouraging its dis- 
agreeable effect upon the mouth. 

The teeth, it is presumed, have been properly attended to, and the 
tartar removed by a dentist. All the precautions detailed in speaking of 
the hygiene of the mouth should also be put in force. Besides these, 
three other precautions may be resorted to ; they are : the bath, a diu- 
retic, and the internal use of the chlorate of potassium. 

The bath should be used quite hot at night, and the patient advised to 
remain for a number of minutes in the warm water. Then he should dry 
his skin under very smart friction with a soft towel. In this way the 
circulation of the skin is rendered active, and the dead epidermis rolled 
off in quantities by the friction. The function of the skin as an excretory 
organ is intensified, and more mercury than usual escapes in this direc- 
tion, taking off some of the work from the mouth. 

A diuretic acts in the same way, increasing the excretory activity of 
the kidney, and allowing more mercury to escape from the body by this 
channel. 

Finally, the well-known soothing influence of the chlorate upon the 
irritated mouth and fauces should be called into play. A little less than 
a drachm of the chlorate of potassium in twenty -four hours is generally 
enough. 

I^ Potass, chlorat., 3 i. 

Aquae gaultheriae, f iij. 

M. S. Teaspoonful hourly in a tablespoonful of flaxseed tea. 

As salivation approaches, the stale odor of the breath becomes posi- 
tively offensive, quite peculiar and characteristic — the mercurial fetor, as 
it is called. The tongue becomes heavily coated, and the peculiar, bitter, 
coppery taste of which the patient has been complaining grows sensibly 



246 VENEREAL DISEASES. 

more intense and more disagreeable, especially upon awakening in the 
morning. The gums grow puffy, soft, and fungating along the line of 
the necks of the teeth, more livid in color, bleeding easily upon the light- 
est touch, as during brushing the teeth, even with the softest tooth-brush. 
Finally, the flow of saliva grows more and more profuse, partly watery 
and partly tenacious. It flows over upon the patient's chin, and soils his 
clothes. At night it runs out from the angles of his mouth, and wets 
his pillow. With these signs the stomach is often badly upset, diarrhoea 
comes on, the complexion becomes pallid, livid, the appetite fails, and 
headache is often present, with great depression of spirits. 

At last the tongue may swell so as to be too large for the mouth, and 
with it the lips and cheeks become tumid. Ulcers appear all over the 
inside of the mouth and along the gums. The purple gums bleed freely, 
the loosened teeth project and drop from their sockets, while more or 
less extensive portions of bone, or of the soft parts, necrose and slough 
away. 

Such an intense condition of salivation as that last depicted is very 
rarely encountered at the present day, but it need not be waited for; all 
conditions of active salivation demand prompt measures for their relief. 

All the means of relief already detailed under the head of hygiene of 
the mouth, and directed for the restraint of salivation when the gums are 
mildly touched, should be kept in force, as far as may be, and atropine 
used in solution under the skin. 

No one remedy perhaps acts as kindly as this. Of the following solu- 
tion — 

I^ Atropinse sulph. , . . . . . . . . gi-. i. 

Aquse, 5 i. 

M. 

Mve minims may be thrown under the skin, the effect upon the pupil 
being watched, and the dose repeated every four to six hours until the 
pupils are widely dilated. 

Chlorate of potassium in solution, in cold tea, about one or two drachms 
to the pint, with a scruple of carbolic acid, according to the sensitiveness 
of the swollen mouth, should be constantly used as a mouth wash, and 
gradually, as they can be borne, stronger and more astringent washes. 
To all of these a little carbolic acid should be added, for the mouth and 
its secretions are most foul and need sweetening greatly. A reasonably 
good mouth wash is the following, diluted at first with warm water, 
should it prove too astringent : 

I^ Acid, carbolic, gi'- x. 

Acid, tannic, . . . 3 i. 

Tr. myrrhee, . . . . . . . . • 3 ij. 

Potass, chloratis, . . . . . . . • 3 ij- 

Mellis, . • 1 ij. 

Aquae menth. pip., q.s. ad § viij. 



THE GENERAL TREATMENT OF SYPHILIS. 247 

Peroxide of hydrogen diluted, or a mild solution of borax or of per- 
manganate of potassium, may be used as a substitute for the carbolic-acid 
preparations should the latter be offensive, as they are to some patients. 

Diarrhoea in these cases may be disregarded, unless it is exceptionally 
severe. Nourishment must be maintained mainly by milk, eggs, soups, 
and soft food. The patient should drink water freely. 

Local Treatment. — The local treatment of syphilis, although subor- 
dinate to the general treatment, is nevertheless of great importance in 
many cases. This is especially true in regard to mouth lesions, and those 
occurring about the anus and genitals in either sex. It may also be re- 
quired for aesthetic purposes to remove eruption that shows upon the face, 
scalp, or hands, and to assist in cicatrizing ulcerated areas. 

In connection with a description of the varied local lesions, some of 
the local measures of treatment most appropriate to them will be alluded 
to ; but, for the sake of avoiding endless repetition, it is well to group 
under one head all general remarks about the local treatment of the 
varied lesions of syphilis, only repeating afterward when the treatment 
is to be emphasized. 

In general, then, it may be said that all the local expressions of 
syphilis" should be treated with respect, not irritated by much handling, 
by dirt, by allowing the secretions to be retained and to undergo decom- 
position. Ulcers should be kept clean, discharges of all sorts should be 
frequently washed away, tobacco prohibited when mouth lesions exist. 

Lesions Upon the Skin. — The local treatment of chancre is detailed 
along with the description of the lesion. The early general eruptions re- 
quire no local treatment other than cleanliness, unless it be for such por- 
tions of the eruption as appear upon the face and hands. These portions, 
therefore, may be treated topically while the rest of the eruption is al- 
lowed to subside under general medication. 

The best topical applications for all the forms of secondary and inter- 
mediary syphilis appearing upon the skin are the different preparations 
of mercury. Most of the tertiary lesions do well also under a local use 
of the mercurials ; but some ulcerative forms seem to thrive better when 
dressed with iodoform, nosophen, or aristol. 

The mercurials, to be effective of good by local application, should be 
graded in strength so as to stimulate without irritating the surface. Con- 
sequently there must be a range in the strength of all applications em- 
ployed, and it is well in a given case to begin with a mild ointment, 
increasing its strength according to its effect. Dry lesions call for more 
strength in the local application than excoriated surfaces require. 

The preparations from which have been derived the most service are 
the following : ^ 

' Most of these have appeared in the monograph on " Tonic Treatment of Syph- 
ilis," E. L. Keyes, published in 1896, p. 71. 



248 VENEREAL DISEASES. 

I^ Hydrarg. oleat., . 5-10 per cent. 

Or— 

I^ Hydrarg. chlorid. corrosiv., . . . . gr. i.-v. 

Glycerinse, . 3ss. 

Spts. rect., 

Aquse ros. , . . . . . . . aa § ss. 

M. 
Or— 

I^ Hydrarg. chlorid. mitis, , . . . .3 i.-i j. 

Ungt. aquae ros. ' | i. 

M. 
Or— 

I^ Hydrarg. ammoniat., 3 i.-ij. 

Ungt. aquae ros., § i. 

M. 
Or- 

I^ Hydrarg. oxid. rub., 3 ss.-ij. 

Ungt. aquae ros., § i. 

M. 
Or— 

I^ Ung. hydrarg. nitratis, q.s. 

To be used in the beginning much diluted. 
Or— 

I^ Hydrarg. iodid. virid., . . . . . . gr. xv.-l. 

Ungt. aquae ros. , 3 i . 

M. 
Or— 

!^ Hydrarg. oxid. flav., gr. xx.-3iss. 

Ungt. aquae ros., . . . . > . • 3 i. 
M. 

Among these preparations, perhaps the best are the lotion of the 
bichloride, the white precipitate, and the citrine ointments. One or the 
other of them will be found to serve a good purpose in the case of the 
different cutaneous lesions, dry or moist. 

Ulcerated lesions upon the integument, due to late syphilis, generally 
improve under various local mercurial applications. The black and yel- 
low washes of the pharmacopoeia serve a good purpose, as does also a mild 
solution of the bichloride of mercury, or dusting the surface with calomel. 

Gummatous and serpiginous ulcers sometimes improve under these 
applications, but sometimes they do not. In such case it is well to try 
iodoform in fine powder, or rubbed up into a paste with glycerin, or dis- 
solved in chloroform, remembering that the chloroform solution is some- 
times a painful application. 

' Any other bland excipient may be used. Vaseline is perhaps the best if the 
ointment is to be kept for any length of time, since it does not become rancid. Oint- 
ments made with vaseline, however, are somewhat less active than if another fat is 
used as an excipient, and absorption is more prompt if lanolin be used. 



THE GENERAL TREATMENT OF SYPHILIS. 249 

A watery solution of chloral hydrate does very well in some old, slug- 
gish cases, from gr. v. to xv. to the ounce of water. 

Ulcers on the leg, if old and chronic, often improve at once upon 
the use of Martin's rubber bandage, or any other species of strapping, 
while some phagedenic forms of ulcer ought to be allowed the chance 
of benefit promised by the continuous submersion system described on p. 
191. Chronic syphilitic ulcers with hard edges do well if their edges are 
scarified and poulticed at first. Ulcers communicating with necrosed or 
carious bone, or with sinuses leading into joints, cannot be expected to 
get well until the deeper-seated lesions have been overcome. 

Lesions upon the Mucous Membranes. — Great cleanliness is the 
first requisite in treating syphilitic lesions of mucous membranes. The 
mouth must be subjected to all the rules mentioned in connection with 
the hygiene of the mouth, and astringent mouth washes, as well as some 
of the other measures suggested in cases of salivation (p. 191), may do 
good. Tobacco must be stopped in the case of mouth lesions ; the vagina 
and vulva should be syringed and washed frequently in the event of le- 
sions in this quarter ; constipation must be avoided, and cleanliness en- 
joined whenever the rectum is threatened with trouble or becomes the 
actual seat of lesions. 

Mouth lesions are the most common and most likely to be protracted. 
Steaming the throat and mouth, gargles of peroxide of hydrogen, of infu- 
sion of flaxseed, of warm tea, with or without a little borax, gr. x.-xx. 
to I i., or chlorate of potassium, gr. v.-xv. to 5 i., have an excellent sooth- 
ing efltect in these cases. A certain amount of chlorate of potassium should 
be swallowed, that, by returning into the mouth in solution in the saliva, 
it may keep up a constant, mild, soothing action upon the various lesions. 

One excellent expedient, in cases in which mouth lesions are constantly 
recurring, is to give whatever mercury may be required for general treat- 
ment in the form of tablet triturates of bichloride of mercury, which may 
be allowed to dissolve slowly in the mouth, the saliva being swallowed. 
In this way the local effect of a solution of corrosive sublimate upon the 
mouth lesions is obtained at the same time with the carrying out of gen- 
eral treatment. 

The best local applications to make upon syphilitic mouth lesions are 
solutions of corrosive chloride of mercury. 

I^ Hydrarg. chlorid, corrosiv., . . . . . . gr. ij.-v. 

Spts. rect., 3 i. 

M. 

To be painted over the affected surfaces with a soft brush daily. 

Or, the acid nitrate of mercury, pure, in small quantity, touched upon 
the lesion once a week ; 

Or, applications of the nitrate of silver, or of the nitrate of zinc, solid 
or in solutions of varying' strengths ; 



250 VENEREAL DISEASES. 

Or, the daily use of a solid lump of pure sulphate of copper, which, is 
to be lightly rubbed over the lesion. 

Mercurial fumigations (p. 240) are of the utmost value in many forms 
of mouth lesion. 

In cases of pure gummata of the mouth and throat, it is best not to 
waste time with mercurial local applications, since attention in this way 
may be diverted from the main hope in such cases — the unsparing use of 
the iodide of potassium internally. 

Upon the vulva, vagina, beneath the prepuce, and elsewhere, the 
same general line of treatment is to be followed as for similar lesions 
within the mouth — cleanliness being perhaps of more value than any oth- 
er one local method of treatment. Pedunculated condylomata, or other 
vegetations, may be snipped off and the base from which they grow 
cauterized, or they may be treated with the salicylic acid and acetic acid 
compound (page 59). 

Mucous patches about the angles of the mouth, upon the lips and 
face, generally do well under the local application of the solution of the 
bichloride of mercury. If this does not hurry them away, one or two 
light applications of the acid nitrate of mercury usually leave nothing 
to be desired in the way of efficiency. 

When mucous patches occur about the anus, under the foreskin, on 
the sides of the scrotum, or about the vulva, between the toes, under the 
breast in the female, in any region where overlying portions of the skin 
keep the surfaces of the lesions sodden, retain their secretion, and encour- 
age putridity of the moisture as it collects — in any of these contingencies, 
soap and warm water, followed by a mild dilution of Labarraque's solu- 
tion, of permananate of potassium, or of carbolic acid, are great aids to 
treatment. 

The lesions must also be kept dry, if possible, either by interposing 
layers of thin old linen, absorbent cotton, or prepared lint, between the 
surfaces which lie in contact, or by a plentiful use of some absorbent 
powder, such as talcum, bismuth, oxide of zinc. A very effective way of 
treating these lesions is to dust them plentifully and often with pure cal- 
omel, or with calomel in varying proportions combined with one of the 
inert dry powders mentioned above. 

All that is required besides this, even in bad cases, is to touch the 
separate moist lesions with solutions of nitrate of silver of varying 
strength, gr. x.- 3 i. to the ounce of water; or lightly with the solid stick 
of lunar caustic ; or, perhaps better still, to use the solution of the bichlo- 
ride of mercury already recommended for skin lesions. 



CHAPTER IX. 

THE GENEEAL TREATMENT OF SYPHILIS {Continued). 

The Iodide Preparations. — For tlie purely gummatous lesions no drugs 
equal the iodides given unsparingly. Unfortunately, the popular dislike 
to mercury is shared by many physicians j and these gentlemen, in look- 
ing around for a specific for syphilis which is not mercury, often fall upon 
the iodides and administer them in different vegetable infusions and tinc- 
tures from the very beginning of syphilis, praising themselves and calling 
for the applause of their patients in that they give no mercury. It is better, 
doubtless, to treat early syphilis with iodide of potassium than not to 
treat it at all ; but exactly how much better, it is hard to estimate. The 
iodides have little power in postponing eruptions that are ta come, although 
they do clear up existing lesions. They certainly have little or no power 
in preventing relapse either early or late in the disease. The iodides 
have their place, and a very important place it is ; but it is unfortunate 
that they are accredited with much curative power over syphilis, since this 
notion naturally leads to their abuse, and tends to bring them into 
disrepute. 

Whenever the lesion is gummatous, in most of the intermediary and 
late syphilides, and whenever the proliferative changes of connective tis- 
sue so common in advanced syphilis in the internal organs are going on, 
the iodide of potassium is a power, and an enormous power, which may 
be used to the great advantage of the patient, either alone in very large 
doses in appropriately selected cases, or in combination with mercury, in 
more moderate doses — constituting what is known as the mixed treat- 
ment. 

When, however, the symptoms for which the iodide is used have been 
fairly and entirely overcome, then the mercurials resume sway, and it is 
better shortly to drop the iodides, holding them in reserve for other 
emergencies. 

The preparations of iodine most valuable in syphilis are the iodides 
of potassium and of sodium. The iodides of calcium, starch, and ammo- 
nium are also used, and iodine as tincture, simple and compound, and 
in the shape of iodoform internally. The last may be spoken of first, in 
order to dispose of them. 

Little or no iodine effect can be expected from iodoform internally, 



252 VENEREAL DISEASES. 

given in doses of a fraction of a grain up to five grains at a time. Hill 
has spoken well of it in gumma of the tongue, but we have not found it 
serviceable. The senior author has given thirty grains at a dose, with 
no obvious effect. 

The tincture of iodine and the compound tincture in starch water 
(forming the fresh iodide of starch) may sometimes be used with advan- 
tage. It is very dark to look at, and not pleasant to the taste, being flat, 
rather nauseating than otherwise; but it is, on the whole, bland and 
rather easily digested, and in cases in which the iodide of potassium or so- 
dium was badly borne by the stomach the mixture has value. The tinc- 
tures may be used in doses of ten drops in a tablespoonful or more of 
starch water, and increased up to eighty drops in a claret-glass of the 
diluting fluid. The iodide of starch in the form of a dry powder may 
be used in from gr. x. to xxx. doses. It is very bulky and difficult to 
take. The iodide of starch cannot be relied upon in an emergency. It 
is valuable mainly in some chronic conditions and as an alternate to other 
iodides. 

The iodide of ammonium is generally used in combination with other 
iodides, under the idea advanced by Paget and sustained by Hutchinson, 
that the carbonate of ammonia given in combination with the iodide of 
potassium intensified the action of the latter. 

The iodides of potassium and of sodium and of strontium hold the 
first rank among the preparations of iodine as specifics against syphilitic 
gummata. Of these the first named is the most powerful, but it has the 
disadvantage of being decidedly more irritating to the stomach than the 
iodides of sodium or of strontium. The last named is decidedly the 
easiest to digest, and the best preparation in the market seems to be the 
French imported bearing the name of Chapoteaut. It makes a solution in 
distilled water a grain to the minim. This drug is rather expensive and 
liable to be adulterated. 

The bitter, coppery taste which the iodides produce in the mouth of 
the patient, and most obvious in the morning upon first awaking, is a 
drawback in some cases to the free use of the remedy. Occasionally the 
mouth is made sore by long-continued use of the iodides, the gums get 
tender and spongy, they swell as in true salivation, and a certain amount 
of soreness in the teeth is complained of, together with an increased flow 
of saliva — the whole, indeed, forming a sort of spurious salivation. 
These two lesser evils may be measurably abated : the first, by the use of 
peppermint in some form, both at the time of taking the dose and upon 
awaking in the morning, and by chewing pieces of root licorice ; the sec- 
ond, by the use of astringent mouth washes, diuretics, and such remedies 
as are generally useful in true salivation. 

Besides these lesser evils sometimes attending the use of the iodides, 
there are five other serious discomforts which are attached to their em- 



THE GENERAL TREATMENT OF SYPHILIS. 253 

ployment : acute catarrh^ headache^ iodis7n, cutaneous eruptions, and irri- 
tation of the stomach. 

Acute catarrh, to the extent occasionally of rendering the patient very 
miserable, sometimes comes on at the very beginning of the use of the 
iodides. The patient sneezes and coughs, the eyes grow red and watery, 
the nose runs, and with this sometimes comes an intense pain across the 
brow, and perhaps severe headache. This symptom, like most of the 
others due to the iodides, varies in intensity with the strength of the 
dose. Unlike some of the other symptoms, it often wears off as the iodide 
is continued in use, or at least the patient gets accustomed to it and com- 
plains less. 

The treatment of this catarrh is to keep the skin active by the use of 
warm baths, to give the patient plenty of bland fluids to drink, and to 
encourage the action of the kidneys, the proper channels of exit for the 
iodides. Belladonna internally, in small quantities, has a certain amount 
of influence in controlling the amount of secretion from the nose and 
throat. 

The headache produced in some people by the use of the iodides is 
quite intense. It usually occupies the brow, or the side or the whole top 
of the head. The headache comes on sometimes after a single dose of 
the offending drug, and sometimes is so intense that it constitutes a posi- 
tive bar to the continued use of the remedy. Fortunately, cases of this 
sort are quite rare. 

The only treatment is to give a mild diuretic in combination with the 
iodide, and to add some of the bromide of potassium to the mixture, or 
even a little opium. Fortunately, this idiosyncrasy of having headache 
when taking the iodides is not always an affair of a lifetime ; the patient 
generally outgrows it in time. 

lodism, properly speaking, includes the headache and catarrh already 
alluded to; but the main feature in iodism proper is a peculiar and intense 
nervous depression, with irritability. This occurs in certain individuals 
when they take the iodides. With this depression there may be more or 
less ringing in the ears, pain in the bones, etc. 

Iodism is difficult to overcome by treatment; usually all efforts fail. 
The general means mentioned above for the headache of iodine may also 
be tried here. 

The cutaneous eruptions produced by the iodides are numerous. 
Erythema, with considerable scaling of the skin, and acne, with boils 
about the face, nose, back, shoulders, and buttocks, are not uncommon 
results of their use. Purpura haemorrhagica is produced by the iodides, 
especially in debilitated, anaemic persons who have taken the drug for a 
long time. A peculiar form of pemphigoid eruption occurring in groups, 
and sometimes called hydroa (Hutchinson), is another of the evil results 
of the iodides upon the skin of some patients. 



254 VENEREAL DISEASES. 

The irritation produced in the stomachy and sometimes in the intestine 
by the iodides, especially when used in large doses, is another seriously 
bad quality which they possess. In this way nausea and lack of appe- 
tite may be induced, going on sometimes to diarrhoea, and leading to 
anaemia and loss of strength — misfortunes which do so much to coun 
teract the good effects produced by the drugs. 

This irritation of the stomach and skin attaches often to an imperfect 
elimination of the drug by the kidneys. When a patient is under full 
doses of the iodides, his urine is full of them, as may be demonstrated 
by pouring a little nitric acid into a test tube containing some of the 
urine. The stronger acid attacks the salt and liberates the iodine, which 
colors the urine, lying above the layer of acid. If the kidneys do not do 
their duty properly, some of the cutaneous expansions of the body must 
suffer : it may be the membrane of the nose ; it may be the skin of the 
face or back, or the glands this skin contains ; or it may be the stomach. 
The stomach is also particularly exposed to irritation by direct contact 
with the medicine. This direct contact the stomach always resents, 
especially if the drug be presented to it in a concentrated form, when it 
is empty.* 

The natural deduction from all this is that the kidneys must be kept 
always active, when the iodides are being administered, by the use of 
plenty of water and bland fluids on the part of the patient, as well as by 
diluting the drug largely when it is taken, and giving it always upon a 
full stomach. If these means do not suffice, the dose of the iodide may 
be combined with a more active diuretic — such as the acetate of potassium, 
or the infusion of digitalis, or both. 

Sometimes, in spite of all precautions, the iodides cannot be taken by 
the stomach. Under such circumstances they may be administered by 
the rectum, giving ten- and fifteen-grain doses of the iodide of potassium 
or sodium dissolved in an ounce of warm beef -tea. 

Above, all it must be borne in mind that the iodides should never be 
given solid (in pill form) when their use in large quantities is required. 
Small doses in pill form do very well in some cases, as high as gr. v. of 
the iodide in each pill; but such pills should be given only upon a full 
stomach, or, perhaps better, taken during the middle of a meal. 

When it becomes absolutely necessary to push the iodides, it should 
be done in spite of all obstacles to the contrary. It may be necessary to 
restrict the diet and to give bismuth and a little opium even, but when 
the iodides are needed they must be pushed at any cost. 

The dose of the iodides is about five grains to commence with in an 
ordinary, untried case, and when there is no emergency to deal with. 
This five-grain dose will generally indicate in what way, if at all, the 
patient is to be uncomfortably affected by the iodides. An occasional 
pimple of acne on the forehead or temple is generally all that will be 



THE GENERAL TREATMENT OF SYPHILIS. 255 

seen, with perhaps a little excess of secretion from the mucous membrane 
of the nose during the first few days of the course. For an ordinary 
case, when there is no haste and the stomach is to be respected, the dose 
of the iodide may be pushed by an increase of two and a half grains in 
the dose each week. By such a gradual increase, with a little care, the 
stomach need not be injured, the skin is not likely to give much trouble, 
and the weekly increase in the dose may be suspended when the symptoms 
have fairly yielded. 

No such caution, however, can be indulged in when an emergency is 
at hand. When the soft palate is threatened with rapid destruction by a 
perforating gummy ulcer, when the bones of the nose are crackling under 
the touch, when the functions of the brain are involved or life is threatened, 
then there is no time for hesitation or delay, and it is not necessary to 
ask whether the iodide will agree or not. If it does not agree, it must be 
made to agree — a process which may tax the resources, the ingenuity, 
and the patience of the surgeon to the utmost. Under such circum- 
stances, a dose of ten grains every four hours is a moderate beginning, 
and in one or two days, according to the surgeon's judgment and the 
patient's necessities, the dose may be increased by five or ten grains, and 
so on indefinitely until the symptoms yield or the stomach refuses to 
receive the drug. 

In such a case the stomach must be managed with all care in the man- 
ner suggested above, and opium, if need be bromides or diuretics, with 
bland food, judiciously joined to the iodides in such a way that the stom- 
ach shall have no excuse for rebellion. Limit to the dose there is none : 
the signal to stop increasing the dose in a desperate case is unconditional 
surrender on the part of the symptoms. If the diagnosis has been accu- 
rate and the stomach can be managed, this result will foilow as surely as 
the night follows day. The physician need have no fear, there need be 
no hesitation. If the stomach holds out, and the drug is boldly and in- 
telligently pushed, victory is the one and only result. All minor symp- 
toms of iodism may be disregarded, the eruptive troubles, the catarrh, 
even the headache and depression of spirits, although these last make 
some patients desperate, so that they seem willing to suffer anything 
from the disease rather than to be compelled to continue their medicine. 

The limit to the dose which may be given has not been found. The 
senior author in one case gave two ounces and six drachms each day for 
about ten days. It is rarely necessary, however, even in the most des- 
perate cases, to go higher than three hundred grains a day ; and such a 
quantity is better in its results if administered in six than in three doses, 
always well diluted in milk or aerated mineral water and put into the 
stomach two hours after finishing a meal or one hour before taking food. 

When small quantities are to be given for a considerable time, and the 
stomach has been first tested with a solution to try its temper, the medi- 



256 



VENEREAL DISEASES. 



cine may be given in pill form for the sake of convenience. Tablets of 
varied strength up to five grains of the pure iodide of potassium are now 
found in the shops in the compressed form. They bear transportation 
well if kept in bottles stoppered with a cork. To make up a pill, how- 
ever, of any strength, a little pepper, gum tragacanth, and glycerin make 
excellent excipients. Such a pill when well made grows solid, smooth, 
and quite hard; but its hardness is no obstacle to its digestion, since the 
affinity of the iodides for water is very great, and such pills readily break 
up in the stomach. A fair formula is the following : 

I^ Potassii iodidi, 

PliIv. pip. nig., ....... 

Gum. tragacanth., 

Glycerini, . . . 

M. ft. pil. No. xxiv. 



. 313. 
. 3i. 

aa q.s. 



These pills are not unnaturally large, each one contains five grains of 
the iodide, and they should be taken with or immediately after each 
meal. In many cases they do not disagree, in others jhey certainly do. 

A favorite method of giving the iodides is in combination with some 
bitter vegetable tincture or infusion, which serves the double purpose of 
masking the peculiarly pungent, bitter taste of the drug, as well as in a 
measure assisting its digestion. The taste of the iodide may be still fur- 
ther covered up by the addition of ginger, peppermint, or bitter orange 
to the solutions in one form or another, and the dose thus made actually 
agreeable. Some ammonia may be added, if thought best, out of respect 
to the general conviction that the presence of this drug enhances the thera- 
peutical activity of the iodide. Such a formula as the following is rarely 
objected to : 



I^ Potass, iodid., . 
Ammonise subcarb., 
Tr. cinchonae co., 
Glycerini, . 
Syr. aurantii cort., 



3 1]. 
3 ss. 
3iv. 

?iss. 



M. S. Teaspoonful largely diluted with water after each meal. 

For convenience of administration, when the dose of iodide is to be 
constantly and rapidly pushed, it is well for the patient to have two pre- 
scriptions : one something like the one given above, and another a satu- 
rated solution of the iodide of potassium in distilled water : 



I^ Potass, iodidi vel. strontil iodidi, §1. 

Aquse destillatse, ' q.s. ad fl. § i. 

M. 

Of this solution one minim measured in a minim glass represents a 
grain of the iodide, and it may be very conveniently used, a teaspoonful 



THE GENERAL TREATMENT OF SYPHILIS. 257 

of the pleasantly tasting mixture being mingled with water, and as many- 
minims extra of the saturated solution of the iodide being added to each 
dose as may be required to make the dose of the iodide sufficient, in cases 
in which this is varied a little from day to day. 

It will be noticed in the foregoing prescription that only enough water 
is ordered to make an ounce of fluid in all. As commonly written the 
prescription reads: 

I^ Potassii iodidi, § i. 

Aquse destillatse, . . . . . . . . • 1 i. 

M. 

Such a formula makes more than an ounce of fluid — nearly an ounce 
and a half, in fact — and it takes about seven minims to equal five grains 
of the iodide of potassium. 

All the remarks thus far made have referred to the iodide of potas- 
sium, nothing having been said of the iodides of sodium or strontium. 
The potassium compound is the stronger, being just about twice as 
effective as the sodium combination. How much stronger it is than the 
strontium salt, if at all stronger, is not yet decided. It is therefore to be 
preferred, and in all cases should be commenced with first. When, after 
fair trial and reasonable effort, it has become apparent that the potassium 
iodide is not suitable, and that the stomach will not bear it, then the 
strontium or sodium iodide may be substituted often with very good effect, 
since in this, as in many other cases, the sodium or strontium salt is more 
agreeable to the stomach than the potassium salt. All that has been 
written, therefore, concerning the iodide of potassium is equally applica- 
ble to the iodides of sodium and of strontium for those cases in which the 
stronger drug is not well borne. 

Mixed Treatment. — The mixed treatment is a combination of one of 
the iodides with a mercurial. It is one of the commonest forms of treat- 
ment, and one of the most useful when intelligently directed. It causes 
even the early symptoms to disappear more promptly than if mercury be 
used alone. The overzealous young practitioner, in his early efforts to do 
all he can for his patient, is quite apt to overshoot the mark in trying to 
obtain for his patient all the good possible out of all kinds of medicine. 
He frequently gives the mixed treatment (mercury and potash, as he 
commonly calls it, instead of mercury and iodine, which it more properly 
is), ordering it as soon as he decides that a given chancre is syphilitic. 

There is no advantage in such a course. Mercury is all-sufficient in 
the beginning, and anything like polypharmacy is of doubtful wisdom, 
since the stomach and its integrity constitute the sheet anchor of the 
syphilitic patient in the long run. The patient may have much medica- 
tion to endure, and it is well to spare him in the beginning. Many stom- 
achs submit to the prolonged use of the iodides without a murmur, for 
17 



258 VENEREAL DISEASES. 

years; but there are others which gradually fail in digestive capacity, and 
reduce the patient to a condition of anaemia, with great general nervous 
irritability and prostration, and that, too, without giving rise to any 
marked active evidences of dyspepsia. The iodides, long continued, are 
fully as liable, or more liable to do harm than the mercurials. It may 
become necessary, during a prolonged and obstinate attack of syphilis, to 
use not only the mercurials for a long time, but the iodides also ; and 
when it becomes necessary, let it be done. But this is not an excuse for 
using the iodides out of place, or calling upon the stomach for extra work 
when it is not required. 

The mixed treatment is appropriate in all the slower, more chronic 
symptoms of the intermediary and late stages of syphilis. The basis of 
the treatment is an appropriate iodide, either of sodium, strontium, or 
potassium, as the case may be, and with it a mercurial. The treatment 
may be effectually carried out by giving a suitable dose of the iodide, as 
directed in the last section, and adding the mercury by fumigation, in- 
unction, or separately in pill. It is a little more appropriate, however, 
and perhaps more accurate in dosage when giving the mixed treatment, 
to mix the drugs themselves in the same pill or potion. The best drug 
to mix with the iodides is the biniodide of mercury. Most other forms 
decompose, and the resulting compound is an uncertain amount of bin- 
iodide of mercury, with an equally uncertain quantity of the other mer- 
curial, however much there may be which has escaped decomposition. 

The biniodide of mercury, therefore, may be added to any of the pills 
or fluids already referred to in the section on the iodides, in a dose vary- 
ing from one-thirtieth up to an eighth of a grain. The new ingredient in 
the combination will make no difference in its form or taste, but often 
makes a great difference in its effect upon the patient. 

Some of the pills found in the market are made so as to represent the 
mixed treatment, containing varied proportions of the iodide of potassium 
and the biniodide of mercury. 

In using the mixed treatment, it is often desirable to continue the 
mercury at a given rate while the iodide is steadily pushed. This consti- 
tutes what is called mixed treatment with iodides in excess, an expression 
which will be found to occur several times in this book when speaking of 
the treatment appropriate to some of the various lesions. 

When to cease giviiig the iodides is a question of importance. They 
are useful, most useful, against certain symptoms in syphilis, but they 
cannot claim power to prevent relapse. Therefore we should use them, 
and vigorously too, against the symptoms that they control, but should 
not depend upon them for any more work after the symptoms have yield- 
ed. The main dif&culty in the case is, therefore, how to tell when the 
symptoms in question are thoroughly controlled. A gummatous infil- 
trated patch may gradually melt away under the bold use of the iodides, 



THE GENERAL TREATMENT OF SYPHILIS. 259 

and seem to be entirely gone ; yet, if the iodides be discontinued too soon, 
this patch will relapse in many cases. How can it be, then, that the 
iodides do not prevent relapse? 

The answer to this question may be found by analogy in the study of 
other infiltrations. Gummatous processes are infiltrations, and the terti- 
ary connective-tissue proliferation, the interstitial hypertrophy of organs, 
is an analogous change. These diseased conditions of the tissues extend 
farther than is evident to the naked eye. In the same way cancerous 
infiltrations and epitheliomatous nodules far outreach their limits as ap- 
parent to ordinary inspection. An epithelioma may be burned upon the 
surface, and the nodule apparently destroyed — so much indeed that 
a thin, unhealthy scar may form over the spot; yet the morbid tissue, 
although apparently gone, often remains in the outlying tissues, and in 
such a case local relapse is inevitable. The same is true of lupus, and 
the effect of local applications upon it ; and of carcinoma, and the cutting 
operations to which it is subjected. 

In the same way in syphilitic infiltrations the remedy which removes 
them, the iodic preparations, must be long and patiently continued after 
the local trouble is apparently under control, or local relapse is certain. 
It is customary, therefore, to continue the mixed treatment for months 
after all evident need for the iodides has passed, and then gradually to 
drop 'the iodides and resume the mercurial at the tonic dose. Eventually 
the mercury itself may be gradually dropped after a number of months, 
differing in varying cases, according to the judgment of the physician. 

In some cases of the old syphilis, especially the nervous forms, when 
the iodides have been long given in large doses, the symptoms may after 
a time fail to yield to the drug, while the patient gradually grows thin, 
nervous in the ordinary sense of the term, tremulous perhaps in his move- 
ments, unable to sleep, to digest food, to perform mental work. Some- 
times in such cases the clinical picture suggests the idea of cerebral soft- 
ening, yet the whole may be due to long-continued excess in the use of 
the iodide of potassium. A cure is attained by cessation of the iodic 
course, aided by mental and bodily rest and hypophosphites with strych- 
nine. These are the patients who recover sometimes after a change of 
physician, or after giving up what they call the " old-school " doctor and 
trying homoeopathy. 

Zittmann^s Decoction: — In terminating the general remarks upon the 
routine treatment of syphilis, something must be said about Zittmann's 
decoction. This remedy has long held a respectable place in the minds 
of the profession, and the formula by which it is prepared, in a stronger 
and a weaker decoction, retains its place in the dispensatories. It is a 
remedy of undoubted value in many conditions of late syphilis attended by 
cachexia, loss of appetite, anaemia, and irritable stomach, especially when 
the iodides disagree. Its action is probably largely dependent upon the 



260 



VENEREAL DISEASES. 



laxative influence of the senna which it contains, and upon the general 
combinations which makes the mercury in it acceptable to the stomach. 

There have always existed two great drawbacks to its general use: 
(1) it is difficult to prepare, containing a hos^- of ingredients which must 
be so concocted that much time is consumed in their proper preparation ; 
and (2) its use according to the rules formerly laid down is too irksome 
to be endured by most patients, while the quantities necessary to produce 
any effect (a pint and more a day) cannot be conveniently mastered by 
many patients with delicate stomachs. Then, also, the rules about pre- 
paratory purgation, rest in bed, hot water with one decoction at one time 
in the day, and cold water with another decoction at another time of 
day, smack really more of the wizard than of the sage, and tend to bring 
the remedy into disrepute with honest-minded persons, lay as well as 
professional. 

The truth is probably that judicious purgation, with a light tonic lax- 
ative containing a mercurial, and that too in fair dose, is what does the 
good. In McDonnell's lectures on surgery in 1871,^ there appeared a 
modified Zittmann's decoction which did away with much of the apparent 
superfluity of the older preparation; but even this is too clumsy, with its 
larger and smaller dose, and cold and hot water. It acts just as well 
when reduced to a single combination. A tablespoonf ul is the dose taken 
without water, three or four times daily, regulating the quantity by the 
purgative effect. The following is the formula : 



I^ Hydrarg. chlorid. corrosivi, 

Aluminis, 

Extr. sarsap, 

Glycerini, 

Syr. sennse, 

Spts. anis., 

Extr. glycyrrhizse, 

Aquse fcBniculi, 
M. S. Tablespoonful at a dose. 



q.s. ad 



gr. 1. 

3ss. 

§iss. 
3i- 

! viij. 



The treatment of inherited syphilis, and of syphilitic women during 
pregnancy, will be given under their own sections. 



» Page 114. 



CHAPTEE X. 

SYPHILIS OF THE SKIN. 

The symptoms upon the skin and mucous membranes have always 
given the best field for studying syphilis ; and since the dermatologist has 
brought his powers to bear upon a study of the numerous lesions of the 
skin produced by syphilis, much peculiarity has been found to exist in all 
the lesions due to the disease, and much distinctiveness in form, color, 
grouping, etc. , so that the class of eruptions produced upon the skin by 
syphilis, and known as syphilides, has become well established. The 
syphilides are generally capable of being diagnosticated by the aid of 
simple inspection. Before going into the detail of description of the 
different eruptions it will be well to consider the general characters which 
are shared by them in common. 

Changes in the skin such as the sallowness, the branny condition, the 
lack of lustre in early syphilis, the flabbiness in cachexia, the general 
tawny hue often seen in the same stage, the seborrhoea, the dryness — none 
of these features found upon a syphilitic patient differ materially from 
the same conditions when encountered upon a patient rendered ill by the 
action of some other debilitating cause. They are not therefore syphi- 
litic, except in that they have become so by accident. 

The peculiar characters of syphilitic lesions of the integument — those 
which they possess collectively as a group of affections — may be best stud- 
ied by examining them in detail. They are polymorphisTn, the color and 
form, the absence of subjective symptoms in connection with them, the 
grouping of the lesions, the characters of the scabs and ulcers, and the ap- 
pearance and behavior of the cicatrices. 

Polymorphism is quite a distinctive feature in the early syphilitic ex- 
anthemata. The evolution of the eruption is in successive crops of lesions, 
and some of these go on to a fuller development than others ; therefore, 
in one and the same syphilitic eruption, at almost any period in its course, 
it is often possible to find the most varied lesions associated side by side : 
the macule, the papule, the vesicle, the pustule, the scale, and the pig- 
ment spot. 

Polymorphism does occur in other cutaneous diseases, but it is so con- 
stant in the syphilitic exanthemata as to be worthy of special remark. 
The same morbid spot upon the skin, in going through its evolution, 
assumes the form of several lesions ; but in the general eruption there is 



262 VENEREAL DISEASES. 

always an excess of one lesion or another, and tMs type lesion names the 
eruption (papular, pustular, vesicular, etc., syphilide). 

Color. — The color of syphilitic eruptions is peculiar. The earlier and 
more acute eruptions are pink and red, a color much like that seen in 
ordinary inflammatory states. As the freshness dies out of these erup- 
tions,' however, they assume the syphilitic tint, and in some instances 
they possess it from the start. This tint is simply a certain lividity min- 
gled with red. It has been called by many names, but that which suits 
it best is the raw ham color. The copper color is found, to perfection in 
many of the lesions after they become pigmented, and it often remains 
for a long time in scars left by lesions, and in the areolar border of the 
latter, but this term is less accurate in expressing the tint of syphilitic 
lesions in their period of activity. 

The color is due to the inflammatory process which produces and 
attends the lesions. The superficial vessels become dilated, a certain 
amount of cell infiltration occurs, and the pigment deposits and shows 
through. 

This hypersemia and small amount of pigment makes the raw ham color. 
It is rarely absent in any of the syphilides. As the hypersemia subsides 
and the vessels return to their natural size, the pigment becomes more ob- 
vious, and then the copper color appears. Finally, nothing is left but 
pigment in greater or less quantity, and the color may be that of bronze. 

The pigmentation remaining behind after syphilitic lesions is not 
usually permanent. It clears away promptly in light cases, more slowly 
in others. It remains longest on the lower extremities. It clears up 
from the centre peripherally, leaving any cicatricial tissue which it may 
have involved more white than the surrounding skin. Occasionally, espe- 
cially around a cicatrix in the lower extremity, it remains permanently. 

Form and Distribution. — The earlier eruptions are generalized more or 
less over the whole body, each separate lesion showing a tendency to 
assume the rounded form. Later, the lesions tend to cluster and form 
patches ; they are generally symmetrical in their distribution. The latest 
lesions show little or no tendency to symmetry, but preserve in a marked 
degree the rounded form. Gummatous ulcers are often composed of the 
confluence of several gummata, and the borders of the ulcer consequently 
are made up of segments of large circles. 

Absence of subjective symptoms is a marked feature of syphilitic erup- 
tions. In nearly every case, and in nearly every class of eruption, from 
the macule to the most extensive ulcer, there is customarily an entire 
absence of any itching or pain. This rule, like all others in syphilis, has 
its exceptions. An acute outbreak of an early syphilide commonly occa- 
sions little tingling, but rarely any itching. Ulcers, if connected with 
bone, or upon the lower extremities, often pain considerably, sometimes 
excessively. On the other hand, the scrofulides, and many gouty erup- 



SYPHILIS OF THE SKIN. 263 

tions, with most of the forms of lupus, are equally devoid of subjective 
symptoms, so that this peculiarity of syphilitic eruptions cannot be 
considered to be pathognomonic. Nevertheless, the conspicuous absence 
of itching and pain is a feature of great diagnostic value in connection 
with the syphilides. 

The scabs and ulcers of syphilitic lesions have some peculiarities. The 
scabs are apt to be thick, rough upon the surface, set into the skin at 
their edges, and adherent, unless undermined with pus. There is gener- 
ally also a marked greenish tint in the scabs, whether the latter are dark 
or light colored. This green tint is often due to the admixture of a cer- 
tain amount of blood with the pus forming the scab. The ulcers of syph- 
ilis are round or oval, resemble chaucroidal ulcers. Their borders are 
sometimes undermined, but generally adherent. The floor is pale, uneven, 
more or less pultaceous, the discharge purulent. The edges are abrupt, 
perpendicular. The base may be either hard or soft. 

The cicatrices of syphilitic lesions are quite uniform in character. 
They are round, depressed, smooth, thin, and not adherent, unless lying 
over bone. They are dark at first, from the pigment they contain ; and 
as this clears off centrally, the scar grows white and shining, its white- 
ness intensified and set off by a dark frame of pigment. 

Types of Syphilides. — The eruptions found upon the skin in secondary 
and intermediary (late secondary) syphilis are seven. The last three 
occupy the border line, and may, any of them, be found long after the 
patient has suffered from well-marked tertiary gummatous lesions of bone, 
or of the other tissues. These three occur also just as well entirely within 
the secondary period, and are best classed along with secondary lesions. 
These eruptions are named according to the prominent lesion which 
characterizes them. They are : 

1. Erythematous (roseola or macular). 

2. Papular. 

3. Pustular. 

4. Pigmentary. 

5. Vesicular. 

6. Papulo-squamous. 

7. Tubercular. 

The lesions belonging to the tertiary period, all of which are prone 
to run on to ulceration, to destroy tissue, and leave scars, are three in 
number : 

1. Pustulo-bullous (rupia). 

( a, with infiltrated base (ecthyma). 

2. Pustular syphilide: i i • 

•^ -^ [oj m groups. 

U, as infiltration: i ^' non-ulcerative. 

3. Gumma : -l I 2, ulcerative. 

/ h, tumor. 



264 



VENEREAL DISEASES. 



In connection with all of these occur lesions on the mucous mem- 
branes, which will be considered in their proper place, and varied gen- 
eral symptoms; glandular engorgement, fever, alopecia, etc., some of 
which have already been considered. 

Erythematous Syphilide. — This is the most common and the earliest 
of the general syphilides. It may come on within a month after the ap- 
pearance of chancre, generally six weeks or two months, sometimes later, 
especially if delayed by treatment. It first appears upon the lower part 
of the thorax in front and at the sides, over the belly, and in the flanks. 




~>v 



V- 



m-ii 



/ 



■^AA 






Fig. 86.— Macular SypMlide. (Morrow.) 



A very hot bath will frequently develop it several days before its natural 
date of outbreak. 

The eruption comes out as a series of roundish and oblong macules, 
varying in diameter from one-eighth to half an inch, at first red, then 
tawny, then pigmented. At first the patches are flat, then they often be- 
come covered with minute papular elevations, and sometimes some of 
these papules go on to vesiculation, occasionally even to mild pustulation 
(although this is exceptional). The patch, therefore, is flat or raised, as 
the case may be. At first pressure of the finger causes the mottling en- 
tirely to disappear ; later a slight, livid staining remains behind after the 
removal of pressure; finally, when the spot is fading and has become 
slightly coppery from pigment, pressure has no more effect upon it. 

The spots are never confluent — healthy skin always exists between the 



SYPHILIS OF THE SKIN. 265 

macules ; but upon this skin there may be found a few other lesions some- 
times, such as a papule or a pustule. 

The hands and face, where the skin is tougher, often escape the erup- 
tion entirely. 

The duration of roseola is from a few days to six or eight weeks. It 
may relapse. An annular variety of large patches in groups, tending to 
turn into the scaly form, is found occasionally at the end of the first year 
of syphilis. It runs a slower course than the roseola, occurring soon 
after chancre. If treatment (mercurial) has been commenced before the 
appearance of the eruption, its outbreak is postponed, and it may consist 
merely of a few scattered macules upon the trunk, requiring some dili- 
gence to find them. 

The diagnosis of roseola due to syphilis is easy. The erythematous 
eruptions due to arsenic, bromine, mercury, belladonna, quinine, have 
different situations and groupings, and are attended either by internal 
fever or local itching. Copaibal erythema itches badly. Roseola autum- 
nalis is attended by fever, and measles by its pathognomonic prodromes. 
The glandular, epitrochlear, and post-cervical engorgement, the existence 
of chancre and the throat symptoms (erythema and mucous patches), 
together with the scabs in the hair, the night pains, and the syphilitic 
fever, if present, make syphilitic roseola one of the easiest to diagnosti- 
cate of all the lesions due to syphilis. 

Papular Syphilide. — This eruption may be combined with a roseola, 
or follow the latter ; or it may appear as the first syphilitic eruption. Its 
date of appearance is therefore about the same as that of roseola. The 
papules vary in size, from a minute acuminated papule, such as is seen 
upon the macules of roseola, to a broad, flat papule as large as a 
dime. A common form is the flat, lenticular papule, of about the size 
of a large split pea. These papules are scattered about, not grouped, 
occupy the flanks, the trunk, the extremities, and very often the face 
(Fig. 87). 

The characteristic flat papule commences small, and grows in all direc- 
tions except in height. It is hard and smooth upon its surface at first, 
later it is sometimes slightly depressed centrally. It is pink or red at 
the commencement, but very soon takes on the syphilitic livid tint. It 
sheds its epithelium on top, or the latter dries down quite early and 
cracks around the circumference of the papule. The broken, rough edge 
of the thickened epidermis then curls away, like a dirty lace collar, from 
the base of the flattened papule, giving the lesion a very characteristic 
appearance. The papules gradually sink away, leaving pigmented spots, 
but no scars. They come out successively, and may be found in different 
stages of development upon different parts of the skin. 

On the palm of the hand the papules seem to abort, on account of the 
thickness of the scarf skin. A thickening of the scarf skin seems to take 



266 VENEREAL DISEASES. 

place, of the size of a papule (papulo-squamous) (Fig. 88). Then the epi- 
thelium gets yellow and dry, cracks, and drops out, leaving a clean-cut, 
punched-out circle in the palm, of the size of a split-pea, with a pink, soft, 
dry floor, covered with thin epithelium and an undermined, whitened 
border of thick, raised epithelium, surrounded often by a red areola. 




Fig. 87.— Papular Syphilide. 

These spots often get well without spreading, thus differing from the later 
scaly syphilide of the palm. Sometimes, however, these spots are attended 
by Assuring and undermining of the epidermis laterally, and several spots 
may coalesce. This is not the rule, but exceptional. 

There is a large, flat form of papular syphilide sometimes encountered 
upon the body, but most apt to be found upon the face and scalp. The 
papules are as large as the finger or thumb nail. In the scalp they itch. 
They are of a pale pink color, desquamate readily. Around their edge 



SYPHILIS OF THE SKIN. 



267 



the epidermis gets raised by a sliglit effusion of serum, while the adher- 
ent cuticle, bound down centrally in the large lesion, gives the whole an 
appearance of umbilication which is characteristic. 

A flat, livid papule, sometimes excoriated, sometimes dry, is occa- 
sionally found indifferently situated upon the skin. 

When papules lie in creases in the skin, so that they are constantly 
covered by other portions of integument (under the breast in the female, 
in the groin in fat persons), and are 
thus kept warm and subj ect to fric- 
tion, they are apt to become very 
large and flat. They sometimes run 
together into patches and become 
moist on the surface. They may 
become exuberant and granulate. 
Under these circumstances the 
papule becomes the mucous patch 
of the skin — the flat condyloma. 
They are common about the anus, 
the scrotum, the labia (Fig. 89). 
The gray pellicle upon the surface 
of these lesions recalls the typical 
mucous patch of the mucous mem- 
branes very exactly. The true 
mucous patch of mucous membranes 
is indeed a papule, and the papule 
on the skin is customarily associ- 
ated with the mucous patch upon 
the mucous membranes. 

The duration of the papular 
syphilide is very variable. It may 
come out as the first eruption, 
either alone or mixed with the 
roseola, and continue for a period 
varying from a few weeks to many months. When apparently getting 
well, it sometimes suddenly relapses without apparent cause. The lesions 
on the palms and soles, especially if they run together into patches, are 
particularly obstinate. 

Syphilitic papules, unless they ulcerate, leave no scars. The pigment 
slowly disappears with time, sometimes centrifugally, leaving a pigmented 
margin, which may persist long after the centre has become whiter than 
the surrounding skin. 

The diagnosis of papular syphilide is very easy in typical cases, espe- 
cially if the eruption is copious, and other concomitant signs of early 
syphilis are present. Difficulties may arise, however, when there are 




Fig. 88.— Papulo-Squamous Syphilide of Palm. 
Early stage. 



268 



VENEREAL DISEASES. 



only a few papules. A few acuminated papules can with difficulty, 
if at all, be distinguished from indolent papules of acne, found after 
middle life in gouty people of dark complexion. The pigmented area 
surrounding the site of a papule which has run its course is suggestive, 
but not pathognomonic, of syphilis. In some cases the result of treat- 
ment alone will justify a diagnosis. 

Flat papules, when occurring in an isolated way, late in syphilis, are 
also indistinguishable from similar isolated accidental lesions, due to 
indifferent causes, upon rheumatic subjects. Treatment here again be- 
comes the most valuable aid to diagnosis, or, better still, observation, 




Fig. 89.— Flat Raised Papules around Anus. (Condyloma lata.) 



since isolated syphilitic papules do not reproduce themselves indefinitely, 
while upon certain gouty subjects they recur from time to time with rea- 
sonable regularity. 

Lichen planus, of all eruptions, is with the most difficulty differenti- 
ated from a papular syphilide. The color is identical, and many other 
features are the same. The most positive distinguishing marks are the 
umbilication of many of the solid papules of lichen planus, their wide 
difference in size, their very marked tendency to run into patches, and 
their tendency to arrange themselves in lines with healthy skin between 
the different lesions rather than in circles, as is the case in syphilitic dis- 
ease. Moreover, with lichen planus there are no concomitant symptoms 
of syphilis found in the lymphatic glands or on the mucous membranes, 
which could hardly be the case in an eruption of syphilitic papules of like 
intensity. The palms and soles are much more apt to be spared in lichen 
planus than in a syphilitic papular eruption. 

The flat raised papule (condyloma lata) generally accompanies other 
syphilitic lesions, and is relatively easy of diagnosis. When seen alone 



SYPHILIS OF THE SKIN. 269 

about the anus, a doubt sometimes arises as to whether the lesions may 
not be the ordinary vegetations, the so-called venereal warts, which are 
apt to be found in connection with gonorrhoeal, leucorrhoeal, and other 
discharges — indeed, complicating all manner of uncleanness. 

The venereal wart is more uneven on the surface than the condyloma 
lata, more split up and segmented into pointed papillae, like the ordinary 
" seed wart. " A large cluster of them may grow off from the skin in a 
pedunculated manner. Their color is apt to be more brilliant than that 
of the syphilitic papule, and their situation is less frequently the anus or 
scrotum. They lie most often within the ostium vaginee in the female;, 
under the foreskin in the male. 

Pustular Syphilide. — The pustules of early syphilis are found in two 
varieties : (1) small, scattered, or grouped, arising within a follicle, or 
occurring independently upon an intervening portion of skin; (2) upon 
an inflamed base, but still superficial, not gummatous (superficial ec- 
thyma) . 

The small pustule has no very distinctive marking. It is apt to be 
generalized over the whole body in early syphilis. 

The pustular syphilide may come on as the earliest eruption at six 
weeks, but it does not usually appear before as many months. The scat- 
tered pustules found among a number of vesicles, papules, and erythema- 
tous spots in the polymorphism of the first eruption do not constitute a 
pustular syphilide. In the latter the type lesion is the pustule, grouped 
or discrete. The lesions are found scattered over the whole body, in the 
scalp, upon the face, upon the fingers and palms, over the whole trunk 
and extremities. They vary greatly in size, take severally from one to 
three weeks to reach perfection, and then they usually break and scab, or 
dry down and heal up under the little crust. When they run together 
into superficial patches, they behave in much the same way. 

When the dried-up scabs fall away the livid thickening of the skin 
remains for a considerable period marking the sites of the lesions. 
These livid papules (for such they are) may be marked by a central de- 
pression — the hole left by the suppurated follicle — if the pustule has been 
pierced by a hair ; or they may remain ulcerated on top for a time, finally 
yielding a thin, white, round scar. A ring of pigment around each sepa- 
rate healing lesion in pustular syphilis is rather the rule than the excep- 
tion; but the pigment finally disappears, and the scars are often so faint 
that it becomes hard to detect even traces of them in later years. Groups 
of superficial pustules are much more rare than numbers of discrete pus- 
tules. 

The pustular syphilide is slow. Crops of pustules come out at differ- 
ent times, relapses are not uncommon ; and, unless treatment aided by 
tonics shortens the duration of the affection, it is apt to drag itself along 
during several months. 



270 



VENEREAL DISEASES. 



The diag7iosis of superficial pustular syphilide is generally easy from 
the concomitant symptoms and history. Iritis is apt to complicate it. 
The bronzed areola of the subsiding lesion is a great help to diagnosis. 
A generalized, pustular, superficial, discrete eruption is very rarely due 
to any other cause than syphilis, and the appearance of such an eruption 
should immediately suggest an inquiry into the patient's previous history. 

The superficial ecthymatous 
syphilide is a little deeper, a 
little more intense, being more 
deeply seated than the simple 
early pustular syphilide. It in- 
dicates that the patient has a 
bad type of syphilis, especially 
if it comes on early. It gener- 
ally appears as late as during 
the second year — late enough to 
be called tertiary; but in bad 
cases it often comes on early, 
within a few weeks of chancre, 
and it leaves a faint scar, not 
indicating any considerable de- 
struction of tissue. Occasion- 
ally, on the other hand, it accom- 
panies early malignant lesions 
in very bad syphilis, and destroys 
considerable tissue, which of 
course necessitates a deep scar. 

This syphilide starts as an in- 
filtration of a limited area of skin 
capped by a pustule, or of a patch of skin upon which several pustules ap- 
pear, at first discrete, later confluent. These pustules are generally large 
and flattened ; they may even be umbilicated. The pustules develop rather 
slowly, with little or no pain, and finally scab, an ulcer existing under 
the scab for some time afte* the latter has formed. The pigmented areola 
comes on during the latter part of the development of the pustules. The 
sc^r remains long purple, often raised and thick, generally pigmented, 
and sometimes pitted. Finally the scars become perfectly white, more 
slowly upon the lower than upon the upper extremities. 

The diagnosis of this form of syphilis is not diflicult except in occa- 
sional cases in which, as sometimes occurs, fever runs high with the first 
outbreak of the pustules, and in which umbilication is marked. A mistake 
has been often made in such cases, and the patient has been sent to a 
smallpox hospital. The mistake may be avoided by noticing the more 
sluggish development of the syphilitic pustules in crops, the absence of 




Fig. 90.— Pustular Syphilide, Showiug both Types. 



SYPHILIS OP THE SKIN. 271 

intense pain in the back, tlie history of the case, and the concomitance 
of other (mouth and glandular) evidences of syphilis. 

The superficial ecthyma of early syphilis differs from the deep ecthyma 
of late syphilis, in that the latter is a gummatous infiltration of the true 
skin, has a livid, hard base, and always leaves a depressed, round, white, 
thin, smooth, unpitted scar. 

Pigmentary Syphilide. — This eruption, the very existence of which 
is questioned by some authors, while its syphilitic character is doubted 
by many who acknowledge its existence, was first accurately described 
by Hardy, later by Eournier. 

This syphilide is simply a coloration of the integument, varying from 
a light dirty brown color to almost a black, a mottling formed of patches, 
light and dark. The light areas of skin are sometimes of a natural hue, 
sometimes whiter than the original integument. 

The eruption is generally found upon the sides of the neck, in front 
and on the upper part of the chest ; exceptionally elsewhere, as upon the 
trunk, the hands. It is generally ignored by the patient, and often dis- 
covered only through accident by the physician, or after careful search. 

The lesion has been considered to be the lesion left behind by a rose- 
ola, and at best it is an obscure affection of but little moment. As cor- 
roborative of past syphilis, it may be of some value. It comes on any- 
where in the second half of the first year after chancre, and may last 
many months, but it always finally disappears. It is totally devoid of 
any subjective symptoms, and absolutely uninfluenced by treatment. It 
cannot possibly be mistaken for anything except dirt, pityriasis versi- 
color, freckles, or leucoderma. The first of these washes off; the second 
itches faintly, is a little branny, and furnishes spores for microscopic di- 
agnosis ; the third are more yellow, and never confined to the limited 
region of the sides of the neck and upper part of the chest. Leucoderma 
of the common sort has a different distribution. 

Vesicular Syphilide. — This eruption is rare. Its date of appearance 
is late in the secondary period, generally during the second year after 
chancre. 

The vesicles may be of varied size, but generally are small, acuminated, 
scattered about the trunk and extremities (the face being spared), or clus- 
tered into groups in circles, or segments of circles, upon a livid base .of 
characteristic syphilitic color. Each of the lesions may be surrounded by 
an areola, at first livid, then coppery, and the vesicles may dry up and 
scale, or become purulent and scab over. 

There is a form of vesicular syphilide coming on earlier (within six 
months after chancre), the vesicles being large, umbilicated, upon a red- 
dened base, with an areola at first livid, then coppery. The vesicles 
quickly become purulent. 

All the vesicular syphilides are slow in evolution and apt to be pro- 



272 VENEREAL. DISEASES. 

longed by successive outcrops of new vesicles and clusters of vesicles con- 
tinuing to appear as the first dry up. The livid spots left by the vesicles 
gradually whiten and leave either no scar or pitted cicatrices. 

The diagnosis is easy. The umbilicated vesicle may suggest vari- 
cella, but there is no itching except in the scalp, and other syphilitic 
lesions are apt to accompany this umbilicated form of the eruption. The 
generalized vesicular syphilide does not become confluent and yield an 
oozing surface as does eczema. The color, the areola, the grouping, the 
absence of itching, distinguish it easily from other vesicular eruptions. 

Papulo-Squamous Syphilide. — The papulo-squamous syphilide occurs 
toward the end of the first year of syphilis, or at any period later. It may 
come on long after the tertiary stage has set in, after gummata have ap- 
peared, after bone disease has been inaugurated and cured. Long after 
the patient thinks himself well, several years perhaps after the appear- 
ance of any symptom due to syphilis, an elevated patch of squamous syphi- 
lide may appear upon the face and be improperly called a lupus by the 
physician — or a circinate scaly eruption comes out upon the scrotum and 
here the patient looks upon it as a ringworm. 

Solid patches of papulo-squamous syphilide may occur upon the face 
or any part of the body. The skin is thickened, more or less livid, often 
not distinctly papulated, but infiltrated. The size and shape of the 
patches vary greatly, from small dots to broad, rounded sweeps of erup- 
tion. The livid surface is covered with fine white scales, which are 
tightly adherent. These scales shed off and are replaced by new crops, 
until finally the infiltration disappears and the patch gets well, leaving 
no scar. If the patch has been positively tuberculated as well as scaly, 
round scars, not much if at all pigmented, are apt to be scattered over 
the livid scaly area covered by the eruption, and these scars remain per- 
manent after the affection gets well. 

The circinate foy^m may come on early or very late in syphilis, attack- 
ing any part of the body, but most common upon the scrotum, or about 
the genitals, in either sex. The circle, or segment of a circle, starts 
of a given size, and does not increase like ringworm. A number of seg- 
ments of circles often run into each other, making a festooned, gyrate 
figure. The border of the circle forming the eruption varies in breadth 
up to about a quarter of an inch ; generally it is but little wider than an 
eighth of an inch on the scrotum. The skin enclosed by the segments 
of circles remains sound. The border of the circle is generally distinctly 
papulated, some of the papules being dry, some moist, some scaly, some 
scabbed. About the genitals patients sometimes assert that the eruption 
itches. 

Diagnosis. — Coincident symptoms of syphilis, and the history, to- 
gether with the common situation along the roots of the hair on the fore- 
head, about the genitals, etc., help to make a diagnosis which the effect 



SYPHILIS OF THE SKIN. 



^73 



of treatment will promptly justify if it has been accurate. In color, on 
the other hand, and general arrangement, patches of papulo-squamous 




X 






Fig. 91.— Papulo-Squamons Sypliilide. (Morrow.) 

syphilide are sometimes quite indistinguishable from some forms of pso- 
riasis, and a localized patch on the face is sometimes nearly enough like 
erythematous lupus to deceive a practitioner not expert in the differential 
18 



274 



VENEREAL DISEASES. 



diagnosis of skin diseases. The circinate, scaly syphilide cannot long be 
mistaken for ringworm, since in syphilis the circle does not grow by cen- 
trifugal enlargement. 

The palmar and plantar pajoulo- squamous syphilides are lesions of the 
first importance in connection with syphilis. There are several varieties 
of this eruption. One of them has already been described, namely, the 
round, livid, dry spots on the palm, looking as if a piece of the epithelial 
layer had been cut out with a punch, and the borders of the scarfskin 




Fig. 93.— Palmar Papulo-Squamous Syphilide. Advanced stage. (After Kaposi, Morrow.) 

afterward slightly undermined (I'ig. 92). Besides these spots, which are 
best observed in connection with a generalized papular syphilide, other 
rounded and oblong scaly patches of the palm and sole are encountered in 
syphilis at almost every stage of the disease. 

These are, with few exceptions, round and oval. The different lesions 
commence as livid, red areas, or as round, epidermal patches of a yellow 
color, according as hyperaemia of the surface vessels or cellular infiltration 
is the more pronounced pathological process. As the lesion progresses it 
spreads centrifugally, the epidermis fissures and scales off, and the differ- 



SYPHILIS OF THE SKIN. 275 

ent lesions run into each other, making a large patch with irregular, 
rounded border (Fig. 92). The centrifugal spread of the patches leaves 
a livid, pink centre, free from any special lesion other than hypersemia. 
In the natural furrows of the palm or sole, and at their border, deep fissures 
are apt to form in the edges of the eruption. Friction upon the palm, as 
in rowing, using tools, etc., is an active, exciting cause; much walking 
and ill-fitting shoes act in the same way upon the sole. Elevated livid 
tubercles, more or less scaly, also occur in patches upon the palm. 

Symmetry is not the rule in either palmar or plantar syphilis. 

Diagnosis. — Some forms of lichen urticatus, of eczema, and of pso- 
riasis resemble it very closely. In the first and last of these affections, 
however, the plantar or palmar lesion is never found alone. The charac- 
ter of general eruption upon the rest of the body, therefore, clears up all 
doubt concerning the lesion in question. An eczematous patch, however, 
may be found exclusively confined to the palm. It is apt to itch, it is 
thinner at the edge, shades off into the surrounding integument more than 
the syphilide does. It is not so livid in color, and has no purple border, 
as is sometimes the case in the syphilide. Eczema is more irregular, less 
rounded in outline, much more chronic in duration, as a rule, and apt to 
extend oat over the palm upon the softer skin around. 

Tubercular Syphilide. — This syphilide occurs in two forms — genera- 
lized, or in groups. The generalized form is quite unusual, that in groups 
very common. The former rarely occurs before the second half of the 
first year from chancre; the latter quite exceptionally before the second 
year. Isolated patches of tubercle may come on at any date, many years 
after all traces of the disease have disappeared. 

The general tubercular syphilide is not the papular syphilide in which 
the papules are large. It develops deeply down in the tissue or the true 
skin beneath the papillary layer. It is not a gummy tumor of the sub- 
cutaneous tissue. When it occurs as a generalized eruption, it does so as 
an eruption of patches and groups of clustered lesions in circles and seg- 
ments of circles. Some of the patches are the result of a confluence of 
many tubercles, and then the patch is a solid livid elevation of the skin, 
uneven on the top, and covered with scales. Each separate lesion, if it 
stands alone, is livid in hue, capped with a scale or a small pustule, and 
often surrounded by a livid areola, afterward becoming coppery. The 
different tubercles vary in size from a grain of rice to a good-sized pea, 
and they usually leave a cicatrix when they disappear, whether their sur- 
face has been ulcerated or not. The scar is at first livid, then often pig- 
mented, then white, round, thin, smooth, depressed, not at all retractile. 

The diagnosis is easy. It is hard to imagine an eruption with which 
the tubercular syphilide could be confounded. 

The tuherculo-squamous or tuherculo-ulcerated syphilide in groups is a 
late lesion. It is, indeed, positively tertiary, but often occurs upon the 



276 



VENEREAL, DISEASES. 



border-line. The face is a favorite seat of the eruption, but it may occupy- 
any part of the body. Livid patches of thickened skin constitute the 
eruption. 

Scales upon these patches are quite obvious, but the tubercles may be 




J^^ 







\ ■^ 



-a.; 



Fig. 93.— Tubercular Syphilide. (Morrow.) 



«^ 






^ 






scarcely so, perhaps not visible at all. Sometimes the only reason one 
has to call the affection tuberculo-squamous is the existence of round, 
white, depressed scars upon the surface in among the scales, of the size 
of a pea, marking the site of tubercular infiltrations of the true skin, the 



SYPHILIS OF THE SKIN. 277 

interstitial absorption of which has produced the white scars. Generally 
the tubercles are quite plainly visible upon the surface. Sometimes they 
stand, apart, sometimes they run together and enclose areas of healthy 
skin within raised circular borders. 

The evolution of the patch is by the circumferential growth of new 
tubercles. Those first formed disappear, leaving scars without previously 
ulcerating, and upon the old spots where former tubercles have flourished 
and gone away new ones may crop out later and go slowly through their 
changes, leaving scars behind. Ringworm may be simulated by circinate 
patches of tuberculo- squamous disease. 

This syphilide is maintained by the successive outcrop of new tuber- 
cles, and a single patch may thus be prolonged for years. Sometimes the 
infiltration which forms the tubercle goes on so rapidly that the integrity 
of the integument is compromised, ulceration takes place, and a serpigi- 
nous ulcer results, as after the pustular syphilide in groups. 

The diagnosis of tubercular syphilide in groups is very easy if atten- 
tion be paid to the central cicatrices in the patch. These are round, 
white, smooth, and not puckered. In tubercular non-ulcerative lupus 
this quality of scar is not observed, the cicatrix being puckered and 
linear. This feature alone is all that is required to make a distinction. 
The lividity of color is much more marked in syphilis than in lupus. 

Tertiary Syphilides. 

The final three sets of eruptions to be considered — rupia, ulcerative 
syphilis, and gumma — are strictly tertiary. They all occur habitually in 
the second year of the disease and later, and they uniformly and inevitably 
destroy the structure of the true skin and leave scars. Treatment post- 
pones their outbreak, or may prevent them from appearing at all. 

Eruptions of this kind may be ushered in while the patient is enjoy- 
ing apparently the most flourishing health. They are all painless, unless 
they involve a bone or joint, as well as the integument. Sometimes 
they accompany the profound cachexia produced by syphilis; but the 
same cutaneous lesions may be found upon patients who present no evi- 
dences of cachexia whatsoever. Rupia, however, whether the patient 
shows cachexia or not, indicates a very bad quality of constitution. 

Pustulo-BuUous Syphilide (Rupia). — Rupia sometimes starts as a flat 
pustule, sometimes as a bulla. The patient may look fat and seem healthy, 
but he is not so, or he would not have rupia. If a bulla first forms, it 
runs on quickly to suppuration, and blood becomes mingled with the pus. 
The first lesion thus formed scabs over, and under the scab ulceration 
commences, yielding pus, which raises the scab from its bed. Meantime 
around the scab first formed an epidermal raised ring appears, filled with 
sero-pus. This dries down into a blackish-green scab, enlarging the first 



278 



VENEREAL DISEASES. 



crust, while ulceration goes ou beneath the whole. A new sero-purulent 
subepidermal collar forms again around the lesion, and the process goes 
on repeating itself. 

The new layers of pus supplied from beneath raise and thicken the 
scab, and if this process continues long without much increase in the area 



/ 




.**■ js 






i^ 



■"■^- 



w 




Fig. 94.— Rupial Syphillde. 



of the patch by the formation of circumferential bullae, as may be the case, 
a horn may be formed sometimes an inch long or more, and in any case 
the roughened crust comes to bear a close resemblance to an oyster shell, 
and pressure upon it generally causes pus to ooze out at one of the edges 
of the sore. If the scab gets detached another may form, or the lesion 



SYPHILIS OF THE SKIN. 



279 



may progress as an open or a partly scabbed ulcer, with a livid or pulta- 
ceous base and sharp-cut borders. Sometimes cicatrization goes on under 
the scab, which finally falls off, leaving a livid cicatrix, generally covered 
with ridges, drawn and puckered in part, sometimes surrounded by a cop- 
pery areola, sometimes having only a livid border. In almost all cases 
the scars eventually become white. 

Tertiary Pustular Syphilide,— In tertiary disease the pustular syphi- 
lide is found in two forms. As a pustule with an infiltrated base, ec- 
thyma, and as a patch of pustules 
beneath which destructive ulceration 
goes on. 

The deep ecthymatous pustule is 
a general gummy infiltration of the 
skin, capped with a pustule, which 
usually goes on to ulceration. 

The gummatous thickening of 
the skin is obvious in the case of 
single isolated ecthymatous lesions, 
but it becomes lost as the single 
lesion ulcerates or the patch of 
ecthymatous pustules spreads. 
When this thickening is present it 
exists as a lurid, painless, hard lump, 
often surrounded by a bronzed areola, 
especially upon the lower extremity, 
as the isolated ecthymatous spot gets 
old. 

The thick green crust which 
forms upon the top of an ecthyma- 
tous pustule resembles a rupial crust. 
Its edges are thm, and frequently 
are depressed beneath the level of 
the surrounding skin, making the 
latter look like a setting which holds 

the scab in place. These scabs are quite adherent, and may remain at- 
tached until cicatrization is complete (Fig. 95). 

The cicatrix of a single deep ecthymatous spot is the typical syphilitic 
scar, smooth, thin, white, depressed, non-adherent. At first it is livid, 
and it remains in most cases surrounded for a long time by a border of 
pigment. 

The favorite seat of deep ecthyma is the lower extremities — but 
it may be found anywhere upon the body, and is not uncommon on the 
face. 

When several ecthymatous lesions run together, an ulcer may result, 




Fig. 95.— Tertiary Pustular Syphilide. 



280 



VENEREAL. DISEASES. 



which may become serpiginous, and creep over a considerable extent of 
surface, often getting well on one side as it advances toward the other 
(Fig. 96). 

Ecthyma does not necessarily indicate a bad condition of the patient. 

The pustular syphilide in groups generally comes on late in syphilis. 
A red spot appears, which quickly becomes covered with small pus- 



1 



J 







V 



Fig. 96.— Ulcerous Syphilide. 



tules. These run together and scab, and beneath the scab ulceration goes 
on. As the ulcer grows, so does the scab, and if the latter falls off or 
is removed, a new one forms. The secretion beneath the scab is scanty, 
and the crust, therefore, does not become rupial. 

Finally, when the patch has reached a considerable size in some cases, 
the new pustules around the edges upon the livid areola cease to form, 



SYPHILIS OF THE SKIN. 



281 



the whole patch dries up and contracts, cicatrizing under the crust. 
When the latter falls, a livid scar is left, with a bronzed areola. The 
centre whitens, the areola generally, but not always, disappears. 

A serpiginous ulcer may result from this lesion, as it may from 
ecthyma, or from rupia. 

An error in diagnosis is not probable. The pustular scrofulide gen- 
erally comes early in life, and the lesion with its ulcer has different 
characters. 



'S^ii> 




fep'"' 




Fig. 97.— Tertiary Syphilitic Ulceration. 



The syphilitic tertiary ulcer is not an especial affection. It is a second 
stage of rupia, ecthyma, patches of tubercles, or of pustules, or a sequence 
of gummy infiltration, or of gummy tumor of the skin. 

The ulcer always has similar characters, whether destroying in depth 
or running superficially upon the surface (serpiginous ulcer). The ulcer 
has perpendicular edges, hard, livid (generally), adherent borders, a livid, 
pultaceous floor (sometimes smooth and shining), and often a hard base. 
These lesions are painless for the most part, unless they involve the peri- 
osteum from being situated over it, as on the shin, or unless they become 
inflamed from injury, or by position, as on the lower extremity. 



282 



VENEREAL DISEASES. 







The syphilitic ulcer may remain stationary, it may eat downward, 
exposing a bone, destroying the periosteum, and leaving a piece of bare 
bone in the floor of the ulcer. This bone, at first white, becomes black. 
It often dies, gradually separates from the healthy bone beneath, and is 
thrown off. The deep, destructive ulceration which deforms the nose 

generally follows a gummy tumor or gummatous 
infiltration. The same may be said of the de- 
; ^;^ o; •/;:' structive ulcer of the penis. 

Serpiginous ulcers are those which spread 
superficially, either in all directions or, advancing 
in one direction, get well in the other. 

Great care must be exercised to distinguish a 
tertiary ulcer upon the tongue or lip from an epi- 
thelioma, upon the penis from a phagedenic chan- 
croid or an epithelioma, 
upon the nose or face from 
an ulcerative lupus or a 
rodent ulcer. The pecul- 
iar characters of syphi- 
litic ulcers, so often al- 
ready detailed, ought to 
be sufficient to guide to a 
diagnosis in most cases. 
In all cases of doubt the touchstone of treatment, if intelligently applied, 
will clear up the question promptl3\ 

Gumma of the Skin. — Tubercular and ecthymatous patches are cer- 
tainly the seat of gummatous infiltration. There is also a true gumma 
of the skin, which appears as a general infiltration, and another form 
which takes the shape of a circumscribed tumor. Either form may ulcer- 
ate ; the latter habitually does so unless arrested by treatment. 

Diffuse gummatous infiltration of the skin is not common. It occurs 
as a patch of livid redness, hard, raised, somewhat scaly on the surface, 
perhaps for a long time smooth and shining. Upon this surface little 
prominences may appear, which quickly ulcerate. The ulcers run together 
and behave like the syphilitic ulcers already described, remaining sta- 
tionary or becoming serpiginous, but not destroying in depth. Rarely 
the patch sinks away, leaving a general thinning of the skin behind, but 
no distinct scar as such. 

Gummatous infiltration of the skin presumably precedes all ulceration 
of the serpiginous sort, whether coming on as a sequence to rupia, ecthyma, 
or any other lesion ; and the infiltrated patches bearing tubercles, scales, 
or pustules owe their infiltration undoubtedly to an analogous patholog- 
ical condition. 

The gumma proper of the skin is, strictly speaking, the syphilitic 



Fig. 98.— Tertiary Syphilitic Ulceration of the Arm. 



SYPHILIS OF THE SKIN. 283 

tubercle. The gummy tumor, yielding an ulcer on the skin, is generally 
a localized accumulation of gummatous cells in the subcutaneous connec- 
tive tissae. These are first noticed as hard, shot-like bodies beneath the 
skin. They are absolutely insensitive upon manipulation. The skin is 
freely movable over them, and they themselves are not attached firmly to 
the surrounding or underlying parts. In this state a subcutaneous gumma 
may remain for months, and sometimes gradually disappear even without 
treatment, leaving no apparent trace of its former existence. Generally, 
however, unless treatment intervenes, the lump gradually enlarges, at- 
taches itself to all surrounding tissues, softens centrally, and the detritus 
of gummy matter slowly but surely ulcerates its way to the surface. 

The skin over the tumor in such a case becomes livid and thin, the 
soft central spot finally gives way, and the contents of the tumor escape. 
This detritus is composed of broken-down gummatous cells, and the de- 
bris of the intervening tissue which was infiltrated with those cells. 
After discharging, the gumma remains open as a deep syphilitic ulcer. 

Gummata of the nose are very apt to lead to perforation, destruction 
of bone, and permanent deformity. Gummata occur over the whole 
body. Local traumatisms seem sometimes to call them into existence. 

Wherever the gumma occurs, the tissue which is implicated is certain 
to be destroyed. The remains of the solid parts may become cretaceous 
and encysted, and continue in this state indefinitely. Sometimes gumma- 
tous exudation is entirely absorbed, leaving behind a cyst containing a 
little fluid. This termination is exceedingly rare. 

The treatment of syphilides of the skin is that of the stage in which 
they occur. Local measures are unnecessary in some and very useful in 
other instances. Their consideration is taken up in the section on general 
treatment. 



CHAPTER XI. 

SYPHILIS OF MUCOUS MEMBRANES, LYMPHATIC GLANDS, 
HAIEY PARTS, AND NAILS. 

The mucous membranes of the body, as well as the outside integu- 
ment, are affected by various lesions in the course of syphilitic disease. 
These lesions are few in number. Some of them occur early, some late 
in the disease, others at all times. They are, in the mouth, throat, and 
nose: 

1. Erythematous patches with erosions and superficial ulcers (occur- 
ring at all times). 

2. Mucous patches (occurring in the typical form only during secoii- 
dary syphilis). 

3. Scaly patches (occurring only late in syphilis). 

4. Gummatous ulcers (occurring only late in syphilis). 

Erythematous Patches, Erosions, and Superficial Ulcers. — These le- 
sions, most notable during the earliest general outbreak of syphilis, may 
yet appear in modified form throughout the disease, either in connection 
with the various eruptions or independently. Often, during the syphi- 
litic fever, when the lymphatic glands behind the neck just begin to be 
perceptible, careful inspection will show that the fauces are covered with 
a uniform redness, suggestive of a common sore throat. This redness 
may extend out of sight up into the nares and down below the pharynx. 

With this erythema the patient generally complains of more or less 
pain, and he may be temporarily deaf, or lose his voice for a few days. 

In connection with this redness, excoriations may occur upon the lips, 
upon the throat, along the edges, upon the dorsum, and at the tip of the 
tongue. 

Peculiarly common after the lapse of several years is an augry red- 
dened excoriation of the sides of the tongue, far back near the root, on 
both sides. This may exist for months without ulcer or scaly patch. It 
is kept up by smoking, and by rough edges of teeth, but occasionally 
occurs without the aid of either of these exciting causes. 

Mucous Patches. — The typical mucous patch is a lesioA found only in 
syphilis and in perfection, usually, only in early syphilis. It may come 
on simultaneously with the first erythema of the throat, and contintte to 
appear from time to time throughout the secondary period ; but it is com- 
monly seen in greatest perfection in connection with the general papular 
syphilide of the integument. The forms occurring late in the secondary 



SYPHILIS OF MUCOUS MEMBRANES. 285 

and during tlie tertiary period are usually scaly patches and excoriations, 
resembling tlie squamous syphilide more than the papule. The true mu- 
cous patch is a flat papule with a sodden epithelium capping it. Its con- 
nection with the papule has been touched upon in the description of the 
flat papular syphilide, where it was shown how any flat syphilitic papule, 
kept moist and sodden, becomes a mucous papule of the skin. 

Clinically speaking, the mucous patches are round, or irregularly 
rounded, raised patches of a dirty white color, sometimes red and granu- 
lating, covered with a more or less puriform secretion. In size, they 
vary from a point to large, irregular surfaces, generally produced by the 
confluence of several patches, and capable of reaching almost any dimen- 
sions. They occur about the tonsils, and upon all the pharynx, within 
the lips, or upon the tongue, within the nose, and down in the larynx 
and trachea, where they have been repeatedly observed with the laryngo- 
scope. Unless ulcerated or attended by surrounding erythema, they are 
painless. Often the patient is unconscious of their existence. When they 
ulcerate or inflame, they may become quite painful. 

They relapse frequently, and continue to come out upon the mucous 
membranes, either spontaneously, or, more often, as the result of local 
irritation — a rough tooth, smoking. 

Mucous patches do not leave any scars unless they ulcerate, and even 
then, the ulceration being superficial, the scars are not well marked. 

Scaly patches upon the throat, tongue, and the inside of the lips and 
cheeks are very common during the second year of syphilis and later. 
They take the place of mucous patches, and are frequently called by that 
name. They may occur early enough in syphilis to be associated with 
the true mucous patch, but their natural position is later in the disease. 

They appear as flat, rounded, irregularly shaped patches of a bluish- 
white color anywhere within the mouth, but by preference at the angles 
of the lips, and on the tip, sides, and dorsum of the tongue. They are 
quite flat and insignificant-looking. They are manifestly due to epithelial 
thickening, and their whiteness depends upon this fact. Sometimes a 
limited patch (particularly under the tongue) will take on extensive over- 
growth and yield an adherent white patch of epithelium as thick as a 
piece of blotting-paper. Sometimes these occur also in the angles of the 
mouth. Sometimes the entire dorsum of the tongue becomes covered, 
with this scaly syphilide, giving it a mottled white and blue-white appear- 
ance. 

These patches cannot be scraped off. They are not ulcers. If roughly 
handled they bleed. They are generally sensitive, although not seemingly 
inflaaned, and when large patches exist in the mouth the contact of condi- 
ments causes pain, and eating is accomplished only at the expense of great 
discomfort. Occasionally they ulcerate, but this is not the rule. They 
occur also in the vulva. 



286 VENEREAL DISEASES. 

Smoking, chewing tobacco, all irritants applied to the mouth, the 
rough edges of teeth, lack of cleanliness, are exciting causes of the scaly 
syphilide of the mouth. 

These patches sometimes closely resemble true ichthyosis of the tongue. 

The mingled excoriations and scaly patches found not infrequently 
upon the tongue and in the mouth of persons having a tendency to dry 
eczema, once seen, could not be mistaken for a scaly syphilide. 

Gummatous Ulcers of the Mouth and Fauces. — Besides the slight round 
ulcers and the irregular erosions of the mouth common to the whole period 
of syphilis, three other forms of ulcer occur, namely : the stationary, 
chronic, infiltrated ulcer ; the serpiginous ulcer ; and the ulcerative gummy 
tumor. All of these occur late in syphilis. The infiltrated ulcer is also 
found early in the disease. 

The deep, ragged, brawny ulcer of the tonsil, found in syphilis, may be 
encountered early and late in the disease, alone and coincidently with 
other symptoms. This ulcer occupies the tonsil by preference, usually is 
oval, with its long axis parallel to that of the tonsil. It may extend over 
upon either of the half arches, or upon the soft palate. It may indeed 
occur spontaneously at the angles of the mouth, inside the cheeks, or 
elsewhere. The base is pultaceous, the borders are cut away, generally 
livid, sometimes pink, usually hard and accompanied by a sodden, livid 
condition of oedematous infiltration of all the surrounding tissues. 

The ulcer remains stationary or progresses slowly. It often occasions 
great pain, especially upon swallowing. But little tissue is destroyed, 
and the resulting scars are not deep. 

The serpiginous ulcer occurs later in the disease, and is manifestly a 
gummatous infiltration. The seat of these ulcers is varied. The edge, or 
the upper part of the soft palate, is not infrequently involved, and quite 
often the back of the pharynx. More rarely other parts of the mouth are 
affected. Not infrequently, with this form of ulcer in the pharynx, the 
lar5mx is the seat of tertiary syphilitic disease. 

These tertiary, serpiginous ulcers sometimes remain stationary for 
months, even years, upon the pharynx, giving very little pain. 

Sometimes they advance rapidly, eating off the uvula in a few days, 
and destroying large portions of the soft palate by eating it away from 
the edge inward. When such ulcers get well they occasionally leave the 
pharynx much distorted by cicatrices. 

The gummy, stationary, or serpiginous ulcer of the pharynx generally 
goes with a bad type of disease, and is often associated with profound 
syphilitic cachexia. 

Gummy tumors may appear anywhere within the mouth. Gumma of 
the tongue will be described under the head of syphilis of the digestive 
organs. The gumma of the hard or soft palate is not uncommon, and is 
very dangerous on account of the damage it is likely to cause if unchecked. 



SYPHILIS OF THE LYMPHATIC GLANDS. 287 

A submucous, round, insensitive swelling first appears, not attended 
by pain. Perhaps the gummatous infiltration is diffuse over a limited 
area, and not concentrated into a single nodule. The growth of the gum- 
matous material may be slow at first, but it is often rapid from the start. 

When the tumor has reached a certain size, the mucous membrane over 
it becomes cedematous and rapidly gives way, disclosing a cavity which 
constitutes a gummatous ulcer like that seen upon the skin, with perpen- 
dicular edges and a deeply situated grayish-yellow floor. The diffuse 
infiltration in a similar manner may soften suddenly, and rapid ulcera- 
tion sweep away quite an expanse of tissue. 

Extensive destruction of tissue may ensue unless treatment intervene, 
and large portions of the roof of the mouth may be sacrificed to obscurity 
of diagnosis or lack of therapeutical boldness. 

As a prophylactic measure against syphilitic lesions in the mouth all 
possible sources of irritation should be avoided, and strict cleanliness 
should be observed. For the mild and simple lesions the general internal 
treatment of the disease may be all that is required. 

As regards smoking, it need not be discontinued except in individual 
cases in which it proves a source of irritation. 

In the more severe lesions smoking should be prohibited, a daily mouth 
wash of mild corrosive sublimate (1 ; 4,000-6,000) or some active deter- 
gent (borolyptol) should be ordered and the internal treatment judiciously 
pushed. Sluggish ulcerations are assisted toward healing by the applica- 
tion of a strong solution of nitrate of silver or the acid nitrate of mercury. 
The general treatment is considered under that heading. 

Late manifestations of syphilis in the mouth call for a vigorous course 
of the iodides. 

Syphilis of the Lymphatic Glands. 

As has already been stated, the lymphatic glands receiving the absorb- 
ents from the region occupied by the initial lesion of syphilis undergo 
indolent engorgement. Then follows a rest (second incubation period), 
and then general syphilis. 

At the commencement of general syphilis, usually before the outcrop 
of any general eruption, certain glands become indolently engorged and 
constitute valuable corroborative evidence of the syphilitic nature of any 
other symptom which may subsequently appear. 

The glands which are of clinical value in the diagnosis of general 
syphilis are the epitrochlear and the posterior superficial chain of the 
post-cervical glands, especially the highest two of the chain, those lying 
on the occipital bone, one on either side of the nucha. The post-aural 
glands are also often involved, the lateral glands in the neck, and the axil- 
lary glands. 

The glands become as hard as bullets, freely movable in all directions. 



288 VENEREAL DISEASES. 

and not adherent to the skin. The integument over them is not colored, 
and they are insensitive to pressure, with occasional exceptions, when they 
first come out. They rarely get larger than a good-sized pea. 

The duration of these glandular indurations is quite protracted. They 
appear about six weeks after chancre, and habitually last for months — 
but little, if at all, affected by treatment. They generally disappear dur- 
ing the first year. 

Other glandular lymphatic engorgements do occur constantly in syph- 
ilis in various regions. In connection with mouth lesions, or spontane- 
ously, one or more glands of the neck indifferently situated may suddenly 
swell up, remain enlarged for a long time, perhaps finally suppurating, 
or abscess may promptly form in a gland, running on to a speedy open- 
ing and discharge. 

Sometimes these glandular enlargements reach a great size, soften, 
but fail to discharge, and, not being opened, their contents dry up and 
are absorbed, a caseous, cretified mass being left behind. 

These same changes in the lymphatic glands may occur in the groin, 
axilla, and elsewhere, but are most common in the neck. 

Finally, tertiary gummata are encountered in various glands, internal 
as well as external, which may ulcerate externally, forming gummatous 
ulcers, and may disappear by absorption, especially in response to treat- 
ment. The abdominal glands will be referred to again in connection with 
visceral syphilis, and the consideration of syphilis of the spleen and of 
the suprarenal capsules will be more appropriate there. 

Syphilis of the Hair and Nails. 

The alopecia of syphilis is a feature of early secondary disease, very 
often observed in connection with syphilitic fever and with the first erup- 
tion. It varies greatly in degree, being generally quite moderate and 
confined to the scalp, from which it thins out the hairs to a greater or 
less extent, while occasionally it is very severe, implicates the whole 
body, and perhaps causes the shedding of all the hairs. 

This shedding of the hair in early syphilis is a mere accident, and 
not intrinsically a syphilitic symptom. It is the result of the ansemia of 
early syphilis, and is due to a failure of a full supply of nutrition to the 
hair papillae. This loss of hair is never permanent when occurring in a 
young person. 

Later in syphilis from cachexia, there may be a similar thinning of 
the hair, and in these cases the hair is less apt to grow again. 

Finally, in cases of ulcerative disease, involving the hair papillae and 
destroying them, localized areas of baldness ensue, which are necessarily 
perpetual. 

The treatment of syphilitic alopecia is a general treatment of syphilis 



SYPHILIS OF THE HAIR AND NAILS. 289 

— the treatment of that stage in which the alopecia occurs. There is 
much value in mercury both as a preventive to the fall of hair, and to 
arrest the fall after it has commenced in the alopecia of early syphilis. 
The cachectic form occurring later generally calls for mixed treatment 
combined with tonics. 

The patient should be told to wash his scalp thoroughly once or twice 
a week, either with tar soap or with borax 3 i. to the 3 ij. of hot water, 
or with liquor ammonias, a drachm to the pint of hot water, according to 
the dirtiness of the scalp and the amount of seborrhoeal exudation which 
it is desired to remove. Eather hard brushing with moderately stiff 
brushes is to be recommended. 

Finally, a stimulating lotion should be rubbed every night, in small 
quantities, well upOn the scalp, and into the follicles under the hair. 
Such lotions add a little to the chance of preserving the vitality of some 
of the hairs whose life is only threatened, and encourage the growth of 
the new hair. The following are good lotions : 

I^ Chloral, hydrat., ....... 3 iss.-iij. 

Tr. capsici, ........ 3 vi.-xiv. 

Glycerini, . 3 ij. 

Spts. myrcise, ...... q.s. ad §vi. 

M. 

Instead of the glycerin and bay rum, oil of sweet almonds with 
cologne water may be preferred, as below ; it is slightly more stimulating, 
and leaves the hair softer and less sticky. 

I^ Tr. cantharidis, ...... 3 iiss.-iv. 

01. amygdal. dulcis, . . . . . 3 ij. 

Aquae cologniensis, . . . . . q.s. ad § iij. 
M. 

Syphilis of the nails and of the hair are somewhat analogous. If the 
early eruptions are intense the nails are likely to get thin and lose their 
lustre, to show more white dots than usual, and to become more brittle 
and liable to crack. Later in the disease, when the matrix of the nail is 
more positively influenced by the disease, all of these changes may be 
more marked, constituting a true dry onychia. 

In onychia the nail first thins behind at the base. As it grows for- 
ward, ridges and furrows are seen upon it, parallel at first, and then con- 
verging. The nail, in this way, gets dry, brittle. It looks dirty and 
cracks easily, and is thin, wavy, and irregular from lunula to tip. This 
form of onychia is rare, but less rare than another form, in which, instead 
of thinning, the nail ceases to grow entirely, its tip continues to grow 
forward, but its posterior edge terminates abruptly in a free, jagged mar- 
gin. In this manner the whole nail may grow off and be shed. A new 
nail, perhaps normal, possibly distorted m various ways, ultimately is 
produced to take the place of the lost nail. 
19 



290 VENEREAL DISEASES. 

A more common form of dry, syphilitic onychia than either of the 
above is that in which the nail, usually first at one side of the forward 
edge, becomes thickened (hypertrophic onychia), friable, crumbly, of a 
dirty, yellowish- white color. The whole thickened surface of the altered 
part of the nail cracks, fissures, and splits away in pieces, until a portion 
of the matrix at the side has been left dry and bare. Sometimes a por- 
tion only of the nail, sometimes the whole nail, is involved in this proc- 
ess. The nail which is finally reproduced is nearly always normal in 
structure and appearance. 

All the forms of onychia which have been described are dry and pain- 
less. The patient usually ascribes them to an injury, but they are not 
infrequently symmetrical on both hands. They always get well with or 
without treatment, and their course is invariably ver}^ slow. 

Treatment. — Internal mercurial treatment certainly modifies dry onych- 
ia favorably ; but the effect of treatment is slow. The five or ten per 
cent oleate of mercury may be anointed upon the dry, rough nail at night, 
and the parts protected by a glove finger. Iodides do not exercise so 
favorable an influence upon dry onychia as mercurials, but, as the affec- 
tion often comes on at the end of the second year or later, the combina- 
tion of some form of iodine with the mercurial administered internally 
is not inappropriate. 

Perionychia due to syphilis is somewhat more common than onychia, 
and may be ulcerative or non-ulcerative. A mucous patch may appear 
under the nail or alongside, and, ulcerating, involve the matrix. Ulcer- 
ative and papulo-squamous lesions may grow up to the border of the nail, 
and include the matrix in a fissure or an ulcer. An ulcer preceded by a 
small, painful, livid swelling may start at one side of the nail, and run 
around the border, involving the nail, and causing it to be shed by sup- 
puration of the matrix. Such ulcers are apt to be attended by the forma- 
tion of exuberant granulations at the borders of the undermined nail. 
The secretions are retained in such cases long enough to putrefy and be- 
come offensive in odor. The whole or only a portion of the nail may 
come away, and the ulcer which takes its place may eat down into the 
matrix deeply enough to destroy it. The whole toe or finger may in- 
flame (dactylitis), and the ungual phalanx may be iavolved in necrosis. 
When the ulcer is deep enough to involve the matrix to a considerable 
extent, a healthy nail is not again produced, but, after healing, which 
always takes place, the nail may be represented by a deformed substi- 
tute, or by uneven bands of cicatricial tissue containing varied amounts of 
nail substance. A gummy tumor commencing in the matrix sometimes 
occurs, terminating in ulceration, sweeping away the nail, and threaten- 
ing the whole phalanx. 

The diagnosis of syphilitic onychia and perionychia is difficult. The 
onychia in its different forms is, in many cases, difficult to distinguish 



SYPHILIS OF THE NAILS. 291 

from similar conditions produced by eczema and psoriasis. The ulcera- 
tive form resembles ingrowing nail, but in the syphilitic disease the ma- 
trix is usually involved first, and not secondarily, as in ordinary ingrow- 
ing nail, or in common " runaround." The gummy tumor is not apt to be 
taken for anything else. 

The treatment of perionychia, and of ulcerated matrix generally, is to 
keep the parts scrupulously clean by washing with warm water and green 
soap, by means of a camel' s-hair brush; to remove all dead and raised por- 
tions of nail (often, with advantage, the whole nail), and to treat the stage 
of syphilis in which the malady occurs with the remedies appropriate to 
that stage. The best local applications for the ulcers are iodoform, noso- 
phen, or glutol freely used, black and yellow wash, and the judicious use 
of poulticing, pressure, and nitrate of silver if the granulations are exu- 
berant. 



CHAPTER XII. 

SYPHILIS OF MUSCLES, TENDONS AND APONEUKOSES, 
BURS^, JOINTS AND BONES. 

Syphilis attacks the muscles by involving their cellular tissue in 
hypersemic and hyperplastic changes, or by the formation of gummatous 
nodules. The function of the muscle is always interfered with while 
under the influence of the attack. The diffuse hyperplastic form tends 
to produce atrophy ; the gumma destroys the part of the muscle it occupies. 

Hypercemic myositis may be, and doubtless is, a mild degree of the 
diffuse hyperplastic form. 

The malady in question appears to involve mainly the lower end of 
the biceps cubiti. Other muscles also suffer — notably the triceps in the 
arm. The malady comes on between the sixth and the tenth months, 
oftener in light than in severe syphilis, and usually in patients who have 
suffered from pains in the muscles and fibrous tissues previously in the 
disease. LTsually the affection is unilateral, or, if bilateral, of unequal 
intensity on the two sides. 

It comes on insidiously, and advances slowly. Attempts to move 
the affected muscle cause pain. When the biceps alone is attacked there 
is inability to straighten the arm completely on account of contraction of 
the painful muscle. The tendon at the elbow feels prominent and tense. 
When the triceps is simultaneously involved there is muscular ankylosis. 

Untreated, this affection continues for several months — occasionally 
several years — but gets well eventually, without altering the muscular 
structure. 

The diffuse form of connective-tissue hyperplasia is a chronic myositis 
of specific nature. The substance of the muscle becomes thickened by 
the development of new cells, which go on to organization into fibres, 
contract like all cicatricial tissue upon the muscular elements, and m the 
end lead to atrophy of the muscle, with more or less shortening and loss 
of function. 

In this affection there is no pain, but the muscle gradually shortens, 
diminishes m size, and becomes more fibrous in texture. 

Treatment is of advantage in some cases, even after atrophy has com- 
menced. All cases treated early are favorably influenced by a combina- 
tion of mercury with the iodides. 

Gummatous tumors may form in any muscle commencing in the peri- 



SYPHILIS OF THE BURS^. 293 

mysium. A gumma here, as elsewhere, consists of a round-celled 
infiltration, which finally becomes absorbed, or undergoes coagulation 
necrosis, softens, and finds its way to the surface, acting just as gumma 
does in the subcutaneous connective tissue. 

The symptoms are at first only a tumor in the muscle, which is pain- 
less, and often of considerable size when first discovered. In a large 
muscle the tumor is found to be stationary, when the muscle is thrown 
into contraction ; at other times movable. The skin is normal over the 
tumor until the latter approaches the surface, where it begins to soften, 
and some pain is complained of, especially at night. 

The termination of gumma leads to the destruction of all the muscular 
fibres involved, which are replaced by the formation of new connective 
tissue. Prompt treatment alone can arrest destruction of tissue. 

The diagnosis is possible, in many instances, only by aid of the his- 
tory and concomitant symptoms, and by the effect of treatment. 

Treatment with iodides in large doses is generally promptly effective 
in the earlier stages of gumma. After the mass has softened, it is some- 
times incapable of preventing perforation and discharge. 

Syphilis of Tendons and Aponeuroses. 

The sheaths of the tendons may become the seat of effusion in second- 
ary syphilis, swelling up in triangular form, with the base toward the 
fingers, or the effusion may be less generalized. The swelling fluctuates, 
and usually is unattended by pain. Occasionally, however, pain, heat, 
redness, and interference with function are as great as in inflammatory 
tenosynovitis. 

The tendons about any of the joints may be involved in this process, 
but the affection is rare, and the back of the wrist the most common seat. 

The tendons and aponeuroses are sometimes involved in localized or 
diffuse interstitial connective-tissue thickening, and extensive gummata 
of nearly all the large tendons have been placed on record. Gummata 
of tendons are painless until they create irritation by their size or by 
commencing to soften. When they become painful, the muscle from 
which they spring generally refuses to act. 

Treatment is that of the stage of the disease to which the lesions be- 
long : mercury internally for the early localized type ; mixed treatment 
for the diffused form ; iodides alone for gummata. 

Syphilis op the Burs^. 

The bursse may be attacked in both the secondary and tertiary stages 
of the disease, either as an acute bursitis with effusion, which is rare, 
more commonly by gummatous infiltration. The bursa m front of the 



294 VENEREAL DISEASES. 

patella is the most frequently involved. The bursa on the side of the knee 
and that behind the olecranon have been similarly affected. The ear- 
lier form of this malady appears much like a bursitis from other causes. 
Its diagnosis is easy when other phenomena of syphilis coexist, and on 
account of the fact that it yields to specific treatment. 

The gummatous form may remain indolent for an extended period, 
or, the surrounding tissues having become infiltrated and the overlying 
skin adherent, the tumor may discharge externally, leaving a superficial 
ulcer and a sinus leading down to the infiltrated bursal sac, which may 
persist for a long period. The course of tertiary syphilitic bursitis is 
very protracted. Concomitant symptoms, study of the case, and its his- 
tory must be relied upon to clear up the diagnosis. 

Treatment should be mixed. The effect is much less rapid in the late 
than in early manifestation. The iodides are more powerful in dispers- 
ing the tumor than mercurials, but the combination of mercury with the 
large doses of the iodides seems to increase the effect of the latter. 

Syphilis of the Joints. 

The joints are involved, both in secondary and in tertiary syphilis. 
The joint affection in the former case is attended by pain, spontaneous 
and on pressure, and by fever, which may run to such a height as to 
make the malady assume the form of acute articular rheumatism. There 
is generally some effusion of fluid. The affection always gets well and 
yields to mercury. 

The acute form may also occur, late in syphilis. 

A chronic hydarthrosis, due to tertiary syphilis, without any thicken- 
ing of the structures forming the joint, is occasionally encountered. 

Gummatous infiltration of the small joints, terminating in their dis- 
integration and destruction, sometimes with opening and discharge ex- 
ternally, comes under the heading of dactylitis. 

The larger joints also suffer in tertiary syphilis, their ligaments, cap- 
sule, and the surrounding tissues becoming the seat of gummatous in- 
filtration. 

The gummy deposit takes place in the capsule in a diffused form, 
with localized areas of greater thickening. Together with this thicken- 
ing of the capsule, there occurs slowly an inconsiderable effusion into the 
joint. There is no pain early in the disease and no fever. 

The malady is usually unilateral. As the changes progress nocturnal 
pains often set in, and when in the knee the joint assumes more or less 
of a fusiform shape, recalling white swelling, with which it is ordinarily 
confounded. 

Finally the cartilages soften and disintegrate, gummatous material 
fills the cavity of the joint. Softening of the gumma takes place and 



SYPHILIS OF THE JOINTS. 



295 



discharges externally, or even, in the case of absorption, the joint may be- 
come disorganized, its functions forfeited, and ankylosis ensues. 

The diagnosis of this affection is with white swelling. Ordinarily the 
diagnosis is made by the history and the effect of treatment. 

Treatment. — Mixed treatment, with the iodides in excess, yields 
striking results in this malady. The employment of massage and pressure, 
together with local use of mercurial plasters and of the oleate, assists in 
the rapidity of the cure. 

Dactylitis. — This is an important form of syphilis which involves the 
fingers and toes. It occurs in two forms : the one involving the joint and 




Fig. 99.— Dactylitis of the Toe, diffuse form. (After Taylor.) 

more superficial tissues, the other the bone and joint. Both are gumma- 
tous. 

The first form is a diffuse gummy infiltration of the periosteum and 
subcutaneous tissues. But one phalanx (generally the proximal) may be 
involved, or the whole digit may share in the morbid process (Fig. 99). 

The swelling in this form of dactylitis is firm, ends abruptly, and 
does not shade off into the surrounding skin. It is not attended by 
pain except on motion, and the latter is generally interfered with by the 
swelling. The color of the integument is often a livid, light red, whether 
there is any eruption upon the skin or not. If the disease is allowed to 
progress, the ligaments of the joints next become involved. Effusion 
into the joint is exceptional in this form of disease. Finally, the carti- 
lages erode and the joint is destroyed, the bones becoming implicated at 
this time. 

The course of the affection is slow, and relapse not uncommon. Per- 
sistent treatment is always curative, but, if the cartilages have been in- 
volved or the joint disintegrated, loss of function necessarily follows. 

The other form of dactylitis is a gummy tumor of the bone. One or 
more phalanges may be attacked. The common seat of the tumor in a 
typical case is the proximal phalanx (Fig. 100). Effusion may take place 



296 



VENEREAL DISEASES. 



into a joiDt, and the latter may be involved in the disease even to a greater 
extent than the intervening phalanx. 

The superficial and surrounding tissues often escape implication in an 
extraordinary way. The skin may be of a livid pink from tension, but 




Fig. 100.— Dactylitis of the Proximal Phalanx. (After Berg.) 

not at all structurally altered ; the nail generally escapes, even when the 
ungual phalanx is the seat of the disease. 

The natural evolution of this malady seems to be that it culminates 
after a time, and the gummy tissue, not being organized, is reabsorbed 
without breaking down. Very rarely does the gummy tissue disintegrate 
and ulcerate its way to the surface. As a result of this interstitial ab- 
sorption, the bone atrophies visibly and the phalanx shortens. When 
two bones and an intervening joint have been involved, the shortening 




Fig. 101. 



due to absorption is so coniderable as to reduce the whole finger greatly 
in length. The accompanying cut (Fig. 101) illustrates this condition and 
represents a case of McCready's, pictured also by Taylor. The deformity 
produced was very striking. There had been no ulceration reaching the 



SYPHILIS OF THE BONES. 297 

surface in this case, and the functions of the fingers were comparatively 
good. 

When the centre of a phalanx only is involved in the disease, absorp- 
tion of the gummy material may leave the bone separated in its centre. 
In such a case the two ends generally come together as a false joint, and 
the skin over them contracts, so as to conform itself to the new order of 
things. There is no pain at all, as a rule, in this form of dactylitis. 

The diagnosis in dactylitis is very easy. The diffuse variety can 
hardly be mistaken for any other malady. Gout and all ordinary in- 
flammations are too painful to be confounded with it. The second form 
might be mistaken for enchondroma, which also is painless, and apt to 
appear upon the phalanges. Enchondroma grows more slowly, and is 
more circumscribed in area. A close study of the course of the affection 
will clear up the diagnosis. 

Prognosis. — Syphilitic dactylitis, even if left to itself, always gets 
well ; but may do so at the expense of deformity and more or less inter- 
ference with function. Its progress may be arrested at almost any stage 
by bold and efficient treatment. 

Treatment. — The diffuse form requires mercury in combination with 
iodide of potassium or some other iodide, which (the iodide) must be un- 
sparingly pushed as rapidly as the stomach will allow. The second form 
generally' yields a very ready response to the vigorous use of the iodides. 
The complete success of treatment in any case is slow. 

Syphilis of the Bones. 

The bones may be involved in secondary, as well as in late syphilis, 
the lesion being osteoperiostitis, osteitis, or osteomyelitis — rarefying or 
gummatous. The epiphyseal changes in the long bones will be noticed 
under the head of inherited syphilis. Subperiosteal nodes are found in 
secondary syphilis upon a number of different bones. These nodes, how- 
ever, are not the destructive gummata of late syphilis; indeed, rather 
rarely do they go on to the formation of exostoses, the common termina- 
tion of ordinary nodes in tertiary disease. The secondary syphilitic node 
is often only a subperiosteal hypersemia and infiltration, coming on 
suddenly, perhaps as the result of local injury, disappearing promptly 
under treatment, and leaving behind no trace of its existence. 

Some few of the secondary subperiosteal swellings, however, do lead 
to local thickening of bone, which remains permanent. 

Osteocopic pains commonly occur in secondary syphilis, and often in 
late syphilis as well. They are pains of a splitting, boring character, 
coming on at night in certain bones, sometimes with great regularity 
ceasing toward morning. These pains are probably due to slight perios- 
teal swelling, attended by considerable subperiosteal hypersemia. The 



298 VENEREAL DISEASES. 

warmth of the bed seems to intensify them (Eicord). B.arely the pains 
come on by day, and cease by night. 

They occur about the head and neck, the shoulders, elbows, and 
knees, and in the continuity of the long bones. The previous use of 
mercury has nothing whatsoever to do with their causation ; on the con- 
trary, they are not apt to come at all if mercury has been commenced early 
enough, and they disappear more quickly under the use of mercury than 
under the employment of any other drug. 

In connection with the pains, sometimes when the bone is superficial 
(cranium, tibia), the periosteum is apparently raised a little, and gives 
to the fingers an obscure sense of oedema. 

The night headache of early syphilis is usually an intense osteocopic 
pain. 

Osteocopic pains early in syphilis are favorably influenced by both 
mercury and the iodides, but mercury has decidedly the more power over 
them. When the pains are only moderate, they do not call for any de- 
viation from the general treatment which the stage of the disease calls for 
in which they occur. When they are intense, however, mercury in 
minute doses, frequently repeated, will sometimes relieve them very 
promptly. From one-fifteenth to one-tenth of a grain of calomel may be 
given in this treatment hourly for twelve hours. Then it is well to ar- 
rest treatment for one day, and repeat a similar course on the next. The 
object of interrupting treatment is the fear of salivation or of intestinal 
disturbance, of which there is some danger when this method is pushed 
in susceptible cases. 

When osteocopic pains come on in late syphilis, they generally indi- 
cate a tendency to serious disease of bone, and call for the iodides in large 
doses. The mercurials are also of advantage here, but the iodides out- 
rank them. 

Osteoperiostitis. — The syphilitic node is an inflammatory osteoperi- 
ostitis, terminating generally in new formation of bone. The lump thus 
formed is raised over a variable area in rounded form, which gradually 
shades off into the surrounding tissues. This lump is soft, and at first 
quite painful, especially upon pressure. Manipulation proves it to be 
attached to the bone. The skin over it is freely movable, and not dis- 
colored. There is often oedema, especially m young nodes of large size. 
The pain in these nodes is sometimes considerable, especially if they are 
situated on the shin, and if the patient walks or stands much. The pain 
is quite certain to be intensified at night. 

The bones most often involved are the flat bones (cranium) and super- 
ficial bones (tibia, clavicle, ulna). Local injury, a blow, will sometimes 
cause a node to appear, but neither situation nor local violence is neces- 
sary for their production, for they sometimes grow from the inner table 
of the skull, where they cause great damage by pressure, and they are 



SYPHILIS OF THE BONES. 299 

occasionally found upon a deep-seated bone (femur, vertebral column) 
well down among the muscles. 

The date of appearance of nodes is late in syphilis. Early forms 
do occur, as already mentioned; but they are not important, and gener- 
ally disperse, leaving no trace. 

Their course is generally slow. After remaining soft for a vary- 
ing period, they become firmer, and gradually disappear by absorption 
under treatment. Occasionally a node softens centrally, the skin over 
it becomes involved, red, adherent. The softened node discharges and 
a syphilitic ulcer remains, the floor of which is bone denuded of its peri- 
osteum. This bone becomes black or brown where it is exposed, and 
often a superficial flake necroses, separates in due time, and comes away, 
after which the ulcer heals. On the skull the outer table comes away 
generally, the inner table remaining, perhaps perforated by a number of 
holes through which the dTira mater may be seen and felt. 

Sometimes a node will remain as a hard, fibrous lump, perfectly pain- 
less and as solid as wood for a number of years, causing no inconveni- 
ence. Such a node, after existing for years, may suddenly soften and 
melt away, involving the bone in destruction, large portions of the super- 
ficies of which necrose in the floor of the ulcer which after healing leaves 
a white, puckered, adherent cicatrix, of ten pigmented at the circumference. 

Exostoses. — Finally and most commonly, a node, having existed some 
time, undergoes partial transformation into true bone {formative osteitis) . 
Such new formations of bone cannot be removed by treatment. They 
remain permanent ; but after a time lose their sensitiveness and constitute 
simple exostoses. These exostoses on the inside of the skull may occasion 
dangerous symptoms, such as paralysis and convulsions. 

The form of bony outgrowth due to syphilis, which is at first more or 
less movable and later becomes attached, has been called epiphysary exos- 
tosis. It is an irregularly shaped ridge or prominent pedunculated bony 
formation occurring about the epiphysary ends of long bones, recalling the 
outgrowths seen in rheumatic gout. 

Besides periostitis there may be a general rarefying osteitis (usually of 
a long bone) involving a portion or the whole of a bone in a painful gen- 
eral thickening due to round-cell proliferation in the subperiosteal tissue, 
and cellular infiltration within the osseous canals. 

The diagnosis is not difficult. The course of the growth, and particu- 
larly the nocturnal pains, suggest a search for a syphilitic history, and 
put the physician on the right track to discover the nature of the affection. 

The treatment of osteoperiostitis and rarefying osteitis is that of late 
syphilis. 

Gumma of Bone. — A gummy tumor late in syphilis may form any- 
where in a bone — under the periosteum (gummatous osteoperiostitis) or in 
the medullary tissue (gummatous osteomyelitis). 



300 VENEREAL DISEASES. 

The subperiosteal gumma is found chiefly upon the clavicle, skull, 
sternum, ribs, tibia, ulna. It commences like a node and tends always 
to soften, while the less active node tends naturally to remain organized. 
The gumma is an acute process, like the osteitis and periostitis already 
described, but much more active. Consequently, it is more serious, more 
destructive. 

The gumma, commencing like a node and advancing rapidly, softens, 
attaches itself to the skin and discharges, its puriform debris remaining 
as an ulcer with dead bone at the bottom. Instead of discharging, gumma 
of bone may remain a soft mass for a long time and undergo caseous 
degeneration. 

Gumma of the medullary membrane in the long bones is uncommon. 
The whole bone swells, and finally gives way. Ultimate atrophy of the 
portion of bone involved is to be expected. 

Medullary gumma of the short bones is not very uncommon. A type 
of such formations already described is seen in dactylitis. 

The diffuse thickening of bone, referred to in connection with syphi- 
litic osteoperiostitis, is often a guinmatous process, the connective tissue 
around the vessels permeating the bone, in the Haversian canals and 
canalicules, being the matrix in which gelatinous, gummatous hyperplasia 
occurs, afterward drying up and being absorbed, leaving the enlarged 
bone very porous, or remaining degenerated in the form of cheesy deposits. 

In the flat bones, and particularly in the diploe of the skull-cap, 
syphilitic gumma takes the form of an infiltration, widening the bony 
lacunae, cutting off the vitality of the thin plates of bone involved, and, 
by its gradual increase, separating the two plates of condensed bone from 
each other. Finally, a piece of condensed bone may die and gradually 
exfoliate. The external table of the skull over a considerable area may 
perish in this way (Fig. 102). Eburnation, condensation, and thickening of 
bone take place here as elsewhere with more or less tendency to osteophytic 
and hyperosteal formations. Sometimes the inner table of the skull 
necroses in connection with diffuse gumma of the diploe, leading to changes 
in the dura mater and brain, and to the most serious nervous symptoms. 

When the very thin bones are attacked by gummatous changes they 
ulcerate and in part necrose, portions of dead bone coming away entire. 
This is the rule in the case of the thin bones of the nose, palate, etc. 
The bones of the nose are peculiarly liable to destruction from syphilitic 
processes. 

As secondary results of the changes in bone produced by syphilis, be- 
sides necrosis, caries, and hyperostosis, may be mentioned a fragility of the 
porous bone, rendering its fracture very easy and its repair slow and 
imperfect. Damage may be caused through pressure, by hyperostoses, 
upon soft parts, cranial nerves, spinal nerves, and the eye in orbital 
exostosis. 



SYPHILIS OF THE BONES. 



301 



Finally, it is necessary to emphasize the fact that mercury has noth- 
ing to do with disease of the bone. 

Mercury given in excess to the point of salivation may, and certainly 
does, threaten the maxillary bones, especially the alveolar process^ with 
destruction ; but aside from this, mercury does not cause any symptoms 
which might be, and usually are, produced by the poison of syphilis. 

Treatment. — As a rule, all forms of bone disease, from the painful 
spot to the gumma, respond to the iodides. The treatment is that of 




Fig. 102. 



late syphilis. Mercury is beneficial in the osteocopic pains and all 
lesions occurring early in the disease. 



Syphilis of Cartilage. 

When a joint is involved, or syphilis attacks the expanded end of a 
bone capped by cartilage, the latter naturally softens, becomes eroded, 
and is destroyed by the neighboring disease. The fibro-cartilage of the 
ear is often invaded by an ulcerative, tubercular syphilide starting in the 
superficial tissues. The laryngeal and tracheal cartilages are a very 
common seat of syphilitic perichondritis, occasionally gummatous de- 
posits involve their vitality, and portions of the cartilage may fall into 
necrosis, just as a bone does under similar circumstances. Gummata 
upon the costal cartilages act like the same lesions on bone. The inter- 
vertebral fibro-cartilages are sometimes involved in gummatous processes, 
but rarely so. 



CHAPTEE XIII. 

SYPHILIS OF THE VISCERA. 

The Eespibatory System. 

In the nose, in early sj^philis, erythematous lesions and mucous patches 
are apt to occur. Their symptoms are those of catarrh. Young people 
suffer more than adults from nasal symptoms, and babies with inherited 
disease most of all. The mucous patch and the erythematous lesions 
have the same physical characteristics here as they have in the throat. 

In tertiary syphilis, gummatous ulcers upon the mucous membranes 
of the nose involve its cartilages below and its thin bones above in de- 
struction; and gummy tumors are quite certain to destroy the bridge 
and other portions of the bones of the nose unless arrested by treatment. 
After cure, the bridge of the nose is permanently sunken and its point 
turned up, giving a physiognomy which is almost pathognomonic of late 
syphilis. 

While the destructive process involving the bone is going on within 
the nose, the patient has " syphilitic ozsena, " or, catarrh, which is more 
or less purulent in character. The odor of the breath in these cases is 
peculiarly offensive. The inside of the nose contains yellow and black 
dry scabs closely adhering to ragged ulcers, or to perforations through 
the septum or elsewhere. Pieces of dead bone are frequently discharged 
through the nostrils, or remain as sequestra and keep up the local irri- 
tation. The nasal duct often gets shut up, leading to abscess of the 
lachrymal sac, conjunctivitis, necrosis of the lachrymal bone. The 
Eustachian tube may be closed, and inflammatory trouble in the middle 
ear be set up, leading to deafness. 

If the disease is situated high up in the nasal cavity, the olfactory 
sense may be destroyed or temporarily impaired. 

The diagnosis of the lesions above described rests upon their course, 
clinical characters, and syphilitic history. 

The treatment of lesions of the nasal cavity is that of the stage in 
which they occur. Local treatment for the early erythematous lesions 
should be stimulating. In the late stages the nasal cavity should be 
cleansed with an antiseptic spray and loose pieces of dead bone should if 
possible be removed. 

The Larynx. — The mucous membrane of the larynx suffers from ery- 



SYPHILIS OF THE VISCERA. 303 

thematous and mucous patches in early syphilis. These lesions are the 
same hece as elsewhere on the mucous membranes (see page 284). They 
are the better for local treatment, but get well without it. Mercurial 
inhalations sometimes hasten their disappearance. 

In the tertiary stage chronic inflammation attacks the cartilages of 
the larynx, and deep ulcerations appear upon the mucous membrane, the 
vocal cords, and in the muscles of the larynx. 

Non-ulcerative laryngitis due to syphilis is a chronic, constructive, 
connective-tissue hyperplasia, involving the cords as well as all the tissues 
within the larynx. The newly formed material contracts here as else- 
where, binds and draws together the tissues within the larynx, stiffens 
the vocal cords into unyielding rigidity in the closed state, and, finally, 
may obstruct respiration entirely, no previous ulceration having occurred. 
The cartilages do not become necrotic in this affection, and there is no 
loss of tissue, except of muscular tissue by atrophy from pressure. 

The symptoms of this affection are a hoarseness, lasting for months, 
even years, slight pain on pressure, gradually increasing dyspnoea, the 
voice finally being reduced to a whisper, the patient becoming enfeebled, 
cyanotic, and emaciated. The larynx is stenosed, the mucous membrane 
livid, the intralaryngeal tissues are thickened. Kapid oedema of the 
glottis is liable to come on at any time. 

The diagnosis should be made by direct examination with the laryn- 
goscope. In tuberculous laryngitis there is generally consolidation at the 
apex of the lung, and with the laryngoscope surface ulceration in the 
larynx may be detected, if present. Papilloma of the vocal cords which 
may give all the symptoms of syphilitic laryngitis is distinguished in the 
same manner. 

Treatment is mixed — mercury with the iodides. It must be long con- 
tinued. If commenced early, it is promptly curative ; later, it is slower 
in its action and less effective. In the stage of stenosis, tracheotomy is 
sometimes necessary to relieve impending suffocation. 

Ulcerative laryngitis may accompany the affection last described, or 
occur independently of it. 

The ulcers are like tertiary, gummy ulcers of the pharynx, and may 
occur anywhere within the larynx, on the cords, behind the epiglottis, 
running down in connection with ulcers in the throat, or occurring inde- 
pendently. 

The ulcers may start as in the pharynx, upon the surface and eat in, 
or a gumma may form beneath the perichondrium of a laryng^eal cartilage 
and eat outward, in either case, especially the latter, a portion of the 
cartilage is liable to be involved in necrotic changes and to exfoliate. A 

t gumma of the larynx may work its way out externally, giving rise to 
fistula. 



304 VENEREAL DISEASES. 

laryngoscope. The final cicatrization after cure in these cases may lead 
to the most extensive distortion of the laryngeal cavity, or even to its 
obliteration. 

The symptoms are those of chronic laryngitis intensified. Pain is 
common, with expectoration of pus, mixed perhaps with blood and por- 
tions of sloughy tissue. 

Diagnosis. — The symptoms easily localize the disease, and the diag- 
nosis lies between ulcerative tuberculour laryngitis and destructive can- 
cerous laryngitis. In the former affection the lungs will almost always be 
found to be in an advanced state of tuberculour disease, and in the latter, 
the non-ulcerated masses of new growth can often be seen with the aid of 
a laryngoscope and the diagnosis confirmed by microscopic examination. 

Treatment. — Iodide of potassium should be given in large doses, and 
run up as rapidly as the stomach will stand. Tracheotomy may be called 
for on account of impending suffocation from oedema. Cicatricial changes 
are not favorably affected by treatment, and may be so seriously obstruc- 
tive to respiration as to demand tracheotomy and a permanent tube. 

The Trachea, Bronchi, and Lungs. — The trachea and larger bronchial 
tubes are subject to the same morbid conditions as the larynx, but less 
commonly so. The lesion found in syphilis of these regions consists of 
dense inflammatory connective-tissue hyperplasia, accompanied by ulcera- 
tive changes and more or less resultant narrowing (stenosis) of the tubal 
lumen. It is possible for ulcers on the surface to eat through into sur- 
rounding structures, but such accidents are exceptionally uncommon. 

The symptoms consist of more or less dyspnoea, localized pain, and 
varying lung symptoms, such as cough, rales, expectoration of mucus or 
blood, etc. If the lesion be tracheal the voice is more likely to be im- 
paired. 

The diagnosis is with tuberculous troubles, and rests mainly upon the 
history and concomitant symptoms, and the examination for tubercle 
bacilli. 

The treatment is like that for similar conditions in the larynx. 

The Lungs. — The lungs are affected by syphilis in two ways : in the 
form of diffuse connective-tissue hyperplasia, leading to consolidation by 
interstitial changes ; and in the form of gummy tumor. 

Syphilitic pulmonary fibrosis is very common in inherited disease. 
It is often generalized in both lungs in the infant. In the adult it is 
more commonly circumscribed. The change in either case is an inter- 
stitial thickening of the connective tissue between the air cells, which 
may go on to a total obliteration of the latter in the fibroid transforma- 
tion of the new cells, and sclerotic shrinkage of the morbid tissue. 

The portions of lung involved in the disease are stiff, non-crepitant 
upon pressure, solid, depressed below the level of the surrounding lung. 
They cut like fibrous tissue ; the section is seen to be interspersed with 



SYPHILIS OF THE VISCERA. 305 

yellow points of fatty degeneration, and the bronchial tubes, variously 
dilated and contracted, with thickened walls. The pleura over these 
spots is apt to be involved in the thickening. 

The symptoms of pulmonary fibrosis are not pathognomonic. They 
are identical with those of chronic phthisis. Any portion of the lung, 
apex or base, may be involved, and there are usually the accompaniments 
of fever, short breath, cough, expectoration, emaciation, etc. 

Gumm^ata in the lungs may coincide with fibrosis, or come on inde- 
pendently. They necessarily go on to destruction of the tissues they 
implicate. 

There are no fixed symptoms. The tumor is solid at first, and may 
be made out by percussion, if it is large enough. It may suppurate, and 
discharging into a bronchus, leave a cavity which may be revealed by 
physical signs. There is no pain, and the subjective symptoms are not 
at all distinctive. 

The diagnosis of lung syphilis always rests mainly on the history, the 
result of treatment, and the examination for tubercle bacilli and is con- 
sequently for the most part tentatively experimental. 

Treatment may be rapidly effective of relief — a permanent cure is 
possible. It should be mixed, with large doses of iodide and continued 
for a long period. 

The Digestive Tract. 

The secondary and tertiary lesions of the buccal cavity and pharynx 
have been described already. 

Sclerosis and Gumma of the Tongue. — Sclerosis of the tongue occurs in 
two forms. One superficial, in which the mucous and submucous tissues 
are involved in a general or circumscribed thickening resembling cicatri- 
cial tissue, which may or may not be accompanied by ulcerations. The 
deeper form of sclerosis, which is an extension of the superficial lesion, 
results in local or general thickening of the tongue, the size of which may 
be very great. A lobulated condition is produced which is quite charac- 
teristic. The lobules are separated by fissures of which the central fissure 
is the most pronounced, as this process is deep and extensive the body of 
the tongue is felt to be indurated as well as enlarged. The mucous sur- 
face is changed in color, being either red, pale or dirty white. It is 
generally smooth. Ulcerations may be present as a result of irritation 
or abrasion caused by the teeth. Cases are also reported of partial and 
localized atrophy of the tongue due to syphilis. 

Gummatous lesions of the tongue are especially important and worthy 
of study, because they frequently come on after all evidences of syphilis 
have disappeared, and are suggestive of epithelioma. 

A gumma may commence in any portion of the tongue except its 
under surface, and may be encountered at any time of life. Not very 
20 



306 



VENEREAL DISEASES. 



infrequently it is bilateral, or there may be multiple foci of gummatous 
deposit. The gumma commences without any pain, as a lump deep 
among the muscles of the tongue or under the mucous membrane; never 
superficially at first, like an epithelioma. The lump grows, the mucous 
membrane over it becomes stretched and livid, finally the tumor softens 
centrally, ulcerates its way through the mucous membrane, and remains 
open as a gummatous ulcer, with a deep, sloughy cavity, hard base, 
fissured, ragged, thick, abrupt borders, often undermined at first, but 
always bound down and adherent later on. The ulcer progresses slowly. 
The course of the affection in any case is much protracted, but the ten- 
dency is to ultimate self -limitation, even without treatment, if the general 
health be good; and to cicatrization, with more or less loss of tissue, 
according to the extent and duration of the ulcer. 

The discharge is slight, even when the ulcer is at its height; but 
there may be phagedsena. Pain is absent or inconsiderable, and the 
functions of the tongue are not much disturbed. The lymphatic glands 
escape implication, or are involved only in an inflammatory way. The 
general health may be very little disturbed, or there may be marked 
cachexia. 

The differential diagnosis is with epithelioma of the tongue, and with 
tuberculous ulceration. Tuberculous ulcers commence as white excoria- 
tions without antecedent tumor. The excoriations enlarge and deepen. 
They advance slowly and are very obstinate and hard to heal. Nearly 
always the lungs contain other evidences of tuberculosis. 

The differential diagnosis between epithelioma and gumma of the 
tongue is presented in the following diagnostic table: 



ULCEKATED EPITHELIOMA OF THE 
TONGUE. 

1. Occurs generally late in life. 

2. Possible cancerous antecedents. 

3. The ulcer sometimes occupies the 
seat of former ichthyosis of the tongue. 

4. Commences superficially and ulcer- 
ates. 



5. Lesion is unique. 

6. Occurs on any part of the tongue. 

7. Edges everted, tuberculated, irregu- 
lar, bleeding easily when touched, or 
spontaneously. 

8. Discharge free, ichorous, putrid. 

9. Pain spontaneous, shooting toward 
ear (Fournier). 



ULCERATED GUMMA OF THE TONGUE. 

1. Occurs at any age. 

2. Syphilitic history. 

3. Nothing of the sort. 

4. Commences deep in the tissues, feel- 
ing like a bullet beneath the mucous 
membrane. It softens centrally, and on 
reaching the surface discloses a deep 
ulcer. 

5. Sometimes multiple and bilateral. 

6. Found only on the back and sides 
of the tongue, never beneath. 

7. Edges abrupt, uneven, hard, ad- 
herent, covered with slough, not tuber- 
culated, not bleeding easily. 

8. Discharge slight. 

9. Ulcer usually painless. 



SYPHILIS OF THE VISCERA. 



307 



ULCERATED EPITHELIOMA OF THE 
TONGUE. 

10. Tongue rigid, painful, functionat- 
ing badly. 

11. Microscopic characters those of 
epithelioma. 

12. Lymphatic glands become in- 
volved. 

13. Anti syphilitic treatment of no 
value. 

14. Termination: death by cachexia 
and inanition. 

15. Liable to return if cut out. 



ULCERATED GUMMA OF THE TONGUE. 

10. Functional troubles generally 
light. 

11. Microscopic characters those of a 
degenerating gumma. 

12. Lymphatic glands generally remain 
exempt. 

13. Antisyphilitic treatment generally 
promptly beneficial. 

14. Spontaneous cure without medicine 
possible. 

15. Does not return if cut out entirely. 



Treatment. — Gumma of the tongue usually yields a rapid response to 
iodide of potassium in large doses, if the remedy is given before the tumor 
has softened. After ulceration, the effect of treatment is less rapidly 
effective, but, nevertheless, is generally quite prompt. In cachectic con- 
ditions, and when the stomach will not bear the iodides, the result of 
treatment is slow and often unsatisfactory. 

The (Esophagus, — Gummatous deposits may originate in the oesopha- 
geal walls leading to ulceration and eventually to stenoses from cicatricial 
contraction. 

These lesions are very rare. Their symptoms are pain on swallowing, 
with evidence of some obstruction in the canal. When the ulcers get 
well, the resulting stricture calls" for treatment by dilatation, severe cases 
may require gastrostomy. Specific treatment if begun early enough may 
forestall the formation of stricture, but will not cause its absorption when 
once it has formed. 

The Stomach and Intestines. — Early in syphilis, especially during the 
fever, nausea, indigestion, and other functional troubles of the stomach 
are not uncommon. 

Thickening and ulceration of the stomach have been ascribed to t'^r- 
tiary syphilis, but have not been clearly defined. Presumably these 
lesions occur here as they do in other portions of the alimentary canal, 
but they are more likely to be discovered on the post-mortem table than 
they are to be recognized during lifetime. 

Gummatous ulcers occur both in the small and large intestines. Cases 
have been reported by various observers (Oser, Meschede, Wagner, Black- 
more, and others), the lesions having been found after death. Such ulcers 
may be single or multiple and result sometimes in perforation, followed 
by fatal peritonitis. Continuous diarrhoea with occasional bloody stool 
and colicky pains with the coexistence of a syphilitic history and visible 
lesions elsewhere, would naturally lead to the suspicion of the existence 
of such lesions. 

The Rectum. — In early syphilis there may be ulcers upon the mucous 



308 VENEREAL DISEASES. 

membrane of the rectum and anus which behave like syphilitic ulcers else- 
where. They are generally surrounded by an unusual amount of inflam- 
matory oedema. 

Condylomata lata appear upon the integument of the arms and around 
the genitals. They are mucous patches which grow from the skin instead 
of the mucous surface. They commence as small moist papules and be- 
come elevated by infiltration when they present the characteristic appear- 
ance of flat warty excrescences (Fig. 89, page 286). 

Localized or diffuse gummatous infiltration and ulceration constitute 
another form in which the disease appears in the rectal region. A stric- 
ture produced by this condition may be of only temporary duration. It 
may disappear under treatment. 

Finally there occurs a chronic hyperplastic infiltration into the sub- 
mucous tissue of the rectum (ano-rectal syphiloma of Fournier), dependent 
upon active cellular proliferation. This lesion is slow in forming. Event- 
ually the new tissue becomes fibrous in character and contracts, producing 
a dense fibroid stricture without previous ulceration. Ulceration may 
occur concomitantly, but is not an essential part of the malady. The 
symptoms are those of proctitis with some loss of power in the sphincter, 
followed later by difficulty in defecation, small stools, and constant mucous 
discharge. This condition when fully developed is a permanent one. 

Diagnosis. — When ulceration has preceded stricture of the rectum, it 
is difficult to differentiate the chancroidal form from that occasioned by 
ulcerated mucous patches. 

The true fibroid stricture is more easily recognized. No other malady 
produces the livid, flat, softish, semi-elastic external patches extending 
into the sphincter and weakening its power, attended by the denser infil- 
tration higher up, with little or no surface ulceration and comparatively 
little pain. 

Ireatment. — In all the tertiary syphilitic affections of the digestive 
tract dietary expedients and precautions are essential. The effect of 
mercury in all of these conditions is good hypodermatically or by inunc- 
tion; but it may be necessary to administer the drug so as to spare the 
stomach and intestines as much as possible. The iodides should be com- 
bined with the mercurial treatment in mild doses and pushed with cau- 
tion, largely diluted with water. 

Mucous patches and ulcers, whenever they occur, demand absolute 
cleanliness, washing with green soap and warm water, and careful drying. 
The surfaces may then be dusted with powdered calomel, iodoform, or 
nosophen. 

For ulcers within the rectum suppositories of iodoform, from four to 
eight grains, should be inserted once or twice a day. For sluggish or 
phagedenic ulcers antinosin, the sodium salt of nosophen, is applicable. 
In syphilitic stricture of the rectum enemata are better than laxatives. 



SYPHILIS OF THE VISCERA. 309 

When the contraction is produced by fibroid changes in the wall of the gut, 
the bougie is indispensable ; and in the last stage of unyielding fibrous 
contraction the knife or electro-cautery alone offers a chance of cure and 
holds out hope of comfort to the patient. 

The Peritoneum. — Syphilis does not appear primarily in the perito- 
neum. In connection with syphilitic (especially gummatous) changes in 
the liver, spleen, intestines, ovaries, the peritoneum becomes thickened 
and adherent. 

The Pancreas. — This gland as a result of syphilis has been found by 
Lancereaux and others, after death, to be the seat of connective-tissue 
infiltration and gummy tumors. 

The Liver. — The jaundice sometimes attendant upon the early symp- 
toms of syphilis is due to catarrh of the bile ducts. 

The changes in the liver due to syphilis later in the disease are true 
to the two types of syphilitic tissue alteration : the one constructive — a 
diffuse, cellular hyperplasia, ending in contraction and induration; the 
other destructive — the gummy tumor. Amyloid changes in the liver are 
also ascribed to syphilis. 

Diffuse syphilitic hepatitis occurs in a circumscribed form in the 
liver of adults with acquired syphilis. It goes on to final atrophy and 
cirrhosis, the cicatrix formed by the wasted tissue contracting deeply into 
the organ gives it a nodular and irregular surface, the liver tissue jutting 
out between the puckered, contracted spots in a singular manner. The 
tissue in these limited glandular areas may be normal, or in amyloid 
degeneration. 

The peritoneum over the depressed cicatricial areas occupying the sites 
of old disease is generally thickened. Sometimes the two layers of peri- 
toneum are adherent. 

Gummatous hepatitis occurs as a dense, connective-tissue, radiate 
mass, with cheesy deposits scattered through it, or as a round, cellular 
tumor, degenerated at the centre, and separated from the liver substance 
by a capsule formed of condensed connective tissue. Gummata commence 
in the walls of the vessels between the lobules. They thus envelop the 
lobules, which they destroy. They may be solitary or occur in great 
numbers, and of varied size, interspersed through the organ. 

Symptoms. — The changes in size of the liver due to hepatitis may be 
appreciated by percussion. Inequalities due to extensive cicatricial puck- 
ering of the organ may sometimes be made out by palpation. Symptoms 
in connection with syphilis of the liver are very moderate or absent al- 
together, the lesion or its cicatrix being encountered after death. Pain 
may be complained of, dull or severe, sometimes made worse by pressure, 
especially where there is perihepatitis. Jaundice is the exception rather 
than the rule, but sometimes comes on and lasts long. It may be due to 
pressure of the enlarged abdominal lymphatic glands. 



310 VENEREAL DISEASES. 

Albuminuria and cachexia often accompany syphilitic degenerative 
changes of the liver. When these two symptoms coincide with an irreg- 
ularity of form and indurated lumps, or a fissured edge of the liver, which 
may be felt, the diagnosis of syphilis is readily made. 

Treatment is that of late syphilis — a mixed medication with a prepon- 
derance of the iodides, especially if there be reason to suspect that the 
lesion is gummatous. 

The Spleen. — The common varieties of textural changes which are 
produced in the spleen by syphilis are chronic interstitial infiltration and 
gummatous nodules. The former occurs as a diffuse, connective-tissue, 
cellular hyperplasia, going on to the formation of fibrous tissue which 
contracts and leaves depressed spots, with the peritoneum over them ad- 
herent to neighboring organs. 

The gummata are fibrous nodules of varying size, granular and degen- 
erated centrally; pinkish-gray at first, finally a dirty yellowish-white. 

Amyloid degeneration may be seen in connection with similar changes 
in the liver and kidneys. 

Symptoms. — There are no symptoms of these lesions other than the 
enlargement of the spleen due to syphilis which is sometimes recogniz- 
able. 

The Thymus, Suprarenal Capsules, and Abdominal Lymphatic Glands. 
— The thymus, as a result of syphilis, has been found hardened, en- 
larged, broken down centrally, the seat of diffuse connective-tissue hyper- 
plasia, and of gumma. 

Connective-tissue infiltration and gummatous degeneration of the 
suprarenal capsules are met with in acquired syphilis. 

The abdominal lymphatic glands are subject, in late syphilis, to con- 
siderable enlargement and to gummatous deposits, which may atrophy or 
become cheesy ; or may soften and discharge, generally upon the cutane- 
ous surface, leaving ulcers and fistulous channels of varying extent and 
duration. The pressure of these larger glands may interfere with diges- 
tion or give rise to jaundice. 

Such glandular swellings may be diagnosticated when they can be felt, 
and are best treated by the iodides, with a certain amount of mercury by 
inunction. 

The Vascular System. 

Syphilis of the Heart. — A diffuse pericardial thickening and gumma 
of the pericardium have been occasionally noted after death. 

Diffuse parenchymatous myocarditis also occurs, and most often either 
with the diffuse cellular infiltration or independently as gumma of the 
muscular structure. 

The thick wall of the left ventricle is the most common seat of the 
deposit. 



SYPHILIS OF THE VISCERA. 311 

Anatomically, the gumma of the heart is a collection of small round 
cells, encapsulated and yellowish-white on section, often cheesy at the 
centre. If near the surface, the pericardium or endocardium over them 
is thickened. They are often multiple. 

A general weakening of the heart's action, without any valvular irreg- 
ularity, attended by slight enlargement of the organ and dilatation of its 
cavities, seems to be the only symptom upon which a diagnosis can be 
based. There may be also functional disturbances, such as palpitation, 
dyspnoea, headache, and vertigo. 

The possibility of embolism, due to bursting of a softened gumma into 
the cavity of the heart, must be remembered. 

Treatment is mixed, with preponderance of the iodides. 

Syphilis of the Arteries. — The changes in the large vessels which are 
most common are atheromatous deposits; and these, when they are found 
in a syphilitic subject early in life, before they can be accounted for by 
senile changes, are generally set down as being due to syphilis. 

A diffuse general thickening of the arterial wall, commencing as an 
endarteritis, and sometimes going on to the extent of occluding the 
lumen of the vessel, is a process very common among the small arteries 
in syphilis, especially the arteries of the brain (Heubner). The walls of 
the blood-vessels large and small are the common seat of gummatous 
tumors. 

As a consequence of a syphilitic artorial changes brain symptoms are 
not uncommon, due to a cutting off of a portion of the brain from its 
blood supply on account of partial or entire closure of the lumen of an 
artery through thickening of its walls. Aneurisms are much more com- 
mon upon syphilitic patients than upon others. 

There are no positive diagnostic signs by which the syphilitic nature 
of a presumed or a positive arterial change can be established. When 
such changes occur upon a syphilitic subject, a mixed treatment, with a 
preponderance of the iodides, is indicated. The effect of treatment upon 
arterial lesions is not always brilliant, but often it is of enough value to 
make it well worth while to push it with firmness and continue it with 
patience. 

The effect of syphilis upon the veins is quite similar to that produced 
upon the arteries in both early and late stages. 



CHAPTEK XIV. 

SYPHILIS OF THE NERVOUS SYSTEM. 

Syphilis of the nervous system has in large part passed from the do- 
main of syphilography to that of nervous diseases ; and to-day the patient 
with nervous syphilis turns instinctively to the neurologist. The subject 
is too extensive to receive in this work the full attention it merits ; an en- 
deavor will be made, however, to give a brief exposition of the most im- 
portant facts. 

Causation. — Certain points in the etiology of nervous syphilis deserve 
mention. It is now known, contrary to the older teachings, that the 
nervous system is attacked most frequently within the first three years 
after the original infection. A considerable number of cases occur within 
six months of the chancre. After ten years the danger becomes much 
less. The most systematic and careful treatment in the early stages does 
not procure absolute immunity for the nervous system. It seems prob- 
able, however, that thorough treatment diminishes the danger; and this 
statement receives some support from the currency of the theory that 
nervous symptoms develop most frequently when the early general symp- 
toms were slight and transient — in other words, in the cases in which 
treatment is most apt to be neglected. There is little authority for the 
belief that the nervous system is involved with special frequency when 
the chancre is extra-genital. It has been estimated that of all syphilitics, 
from one and one-half to two and one-half per cent develop lesions in the 
nervous system, exclusive of those of locomotor ataxia and general paresis.* 

Alcoholism, lead poisoning, fatigue and over-exertion, undue exposure 
to the sun or high degrees of heat are among the most important exciting 
causes. Brain syphilis is especially frequent in persons of unusual intel- 
lectual activity ; and in the so-called Bohemians, who lead lives of irregu- 
larity or excess. 

When the affection of the nervous system is hereditary, it usually 
appears in the first two years of life, though it may do so at later periods. 

Pathology. — The anatomical characteristics of syphilis of the central 
nervous system are changes in connective tissue and in the blood-vessels. 
They sometimes originate in the surrounding bones and extend to the 
brain or spinal cord; more frequently, however, in the nervous system it- 

* A percentage which to the authors seems excessively high. 



SYPHILIS OF THE NERVOUS SYSTEM. 



313 



self. In connective tissue they appear as collections of round, polyhedral, 
and branching cells, which may be diffused or gathered together in masses. 
These masses are microscopic, or appear as very small dots, or may at- 
tain the size of large tumors. They are the gummata. They are soft, 
yellowish, poorly supplied with blood-vessels, and have the tendency to 
central necrosis. The changes in the blood-vessels are most important in 
the arteries. Their external coats are thickened and infiltrated with 
round cells, often collected as minute gummata. The endothelial cells of 
the intima proliferate, encroaching upon or obliterating the lumen of the 




Fig. 103.— Cerebral Syphilis. The upper short line points to an eroded aneurism of the basilar artery. 



vessel (obliterating endarteritis). This affection of the arteries may be 
limited to the small vessels in the immediate vicinity of the gummatous 
deposit, or it may involve large and important trunks which are adjacent. 

It also occurs in the larger vessels of the brain, especially in the mid- 
dle cerebral, as an independent and primary affection, constituting pri- 
mary cerebral arteritis, perhaps the most important form of nervous 
syphilis. 

These pathological products ma}^ be circumscribed or scattered through- 
out the cerebrospinal axis. They have the tendency to spread, causing 
adhesions of the membranes to each other and to the surrounding bones, 
and to the nerves. Most frequently the new tissue involves the meninges 
primarily — the internal surface of the dura and the meshes of the pia 
especially. In the brain the pia is affected most frequently at the base, 



314 



VENEREAL DISEASES. 



^1 



U 



the space bounded in front by the optic chiasm, behind by the pons, and 
at the sides by the crura. This is the basal meningitis. The internal 
surface of the dura suffers chiefly over the convexity. This occurs as a 

local or diffuse pachymeningitis. Solitary gum- 
mata also proceed from the dura. 

The primary involvement of the internal 
parts of the brain is more unusual. Still, soli- 
tary gummata occur in the white matter of the 
hemispheres, in the basal ganglia, and (infre- 
quently) in the cerebellum. 

In the spinal cord, the commonest mani- 
festation of syphilis is a meningomyelitis of 
the dorsal region. Others are gummata of the 
internal surface of the dura and cervical pachy- 
meningitis. Solitary gammata of the cord are 
rare. The blood-vessels in the neighborhood of 
the gummatous deposits are always involved; 
but primary spinal arteritis is very much less 
common than the cerebral form. The cranial 
nerves are usually affected by extension of a 
surrounding meningitis. The existence of peri- 
pheral neuritis due to syphilis is doubtful. In 
addition to these changes wrought by syphilis 
in the central nervous system, of an inflamma- 
tory and comparatively gross character, are 
atrophies and dystrophies of the ganglion cells. 
Of these latter little is known. 

Syphilis acts upon the central nervous system 
in three ways : Pirst, the effect on the organ- 
ism of the poison itself, the reaction to which 
is shown by the pathological alterations in con- 
nective tissue, blood-vessels, and nerve cells. 
Of this we know very little. Second, the newly 
formed tissue acting as a foreign body, dis- 
turbing the function of conducting paths and 
of nerve cells. These effects are generally not 
complete, though in the case of large gummata 
they may be serious or fatal. The third and most important effect of 
syphilis upon the central nervous system is obtained through the arteries. 
Ansemia of important parts of the brain is brought about by narrowing of 
the nutrient vessel through its thickened intima or b}' thrombosis. If 
the circulation be not completely shut off, or if it be quickly resumed, 
complete restoration of the affected brain region is possible. But when 
the anaemia is complete or long continued, the tissues soften and disinte- 



Fig. 104.— Gumma of the Dura 
Mater of Spinal Cord. 



SYPHILIS OF THE NERVOUS SYSTEM. 315 

grate, a condition from which repair is impossible. In a small propor- 
tion of cases aneurisms form which may rupture. The basilar artery 
is the most frequent site (Fig. 103). 

Cerebral Syphilis. 

General Symptoms. — Certain general symptoms are found more or less 
constantly in all varieties of brain syphilis, and they are in many ways 
characteristic. The mental state, while it may be maniacal or comatose 
or normal, is often that of inattention, of sleepiness, or dreaminess. The 
patient hears, understands, and can answer ; but he is quiet and sleepy 
and uninitiative ; he is subconscious and sleepy rather than stupid. 
Headache is an almost constant symptom. Its location and character vary 
with the anatomical lesion, but it is almost always worse at night. The 
condition of the pupils may be of great assistance in diagnosis. They are 
often unequal in size, although both respond to light. In other cases 
there is the Argyll-Robertson pupil, i.e., response during accommodation, 
but not to light. In other cases all pupillary responses are lost. < 

In addition to these general symptoms there may be those common to 
any brain disease. Thus vomiting, dizziness, epileptic attacks, etc., are 
frequently met with. Objective sensory symptoms are rare. The patient 
may complain of numbness or tingling down one side, but it is not often 
that anaesthesia is demonstrable. 

A distinguishing characteristic of all the symptoms of cerebral syphilis 
is their fluctuation. They become worse and better by turns ; they ad- 
vance and retreat ; they have a strong tendency to relapse. 

The special clinical forms under which brain syphilis manifests itself 
are in many ways characteristic and cleanly cut. But it must be re- 
membered that syphilis may attack the brain in a variety of ways ; that 
the pathological process may be slight and limited, or extensive and widely 
disseminated ; and that the ultimate effects of the poison are imperfectly 
understood. Thus one of the more sharply defined clinical types of brain 
syphilis may, and frequently does, complicate another, thus creating a 
picture of considerable complexity ; or symptoms of brain syphilis may 
be complicated by those referable to the spinal cord. On the other hand, 
the fact that the brain is invaded may be shown by one symptom only, 
viz., by a cranial-nerve palsy, by sensations of numbness and tingling, or 
by momentary aphasia or loss of power in a limb. Finally, certain 
chronic nuclear degenerations, such as ophthalmoplegia, or certain affec- 
tions of the cortex, such as general paresis, while clinically related to 
syphilis, are yet to be proved to be certainly of syphilitic origin. 

If these limitations are borne in mind, the following descriptions of 
clinical types will be found to cover most of the cases commonly met in 
practice. 

Basal Meningitis. — The earliest symptom of this affection is headache. 



316 VENEREAL DISEASES. 

It is always severe, becoming so intense at night that sleep is impossible 
or seriously interfered with. It is referred especially to the front, sides, 
and top of the head. It is paroxysmal in character. The mental state 
varies. In acute cases there is great restlessness and often active and 
noisy delirium, which may pass into coma. In chronic cases, which are 
more common, there is the characteristic sleepiness and inattention. 
Vomiting is sometimes present. Dizziness is frequent. General convul- 
sions indicate a severe affection. Local twitchings or convulsions in 
muscles partly paralyzed sometimes occur. Fever is present sometimes 
in acute cases, though it is generally not high except in terminal stages. 
Extreme thirst is often complained of and polyuria is a frequent symp- 
tom. The urine may contain sugar. All these symptoms oscillate in 
their severity, and one or another is at times the more prominent. 

The almost constant location of basilar meningitis in the middle fossa 
of the skull produces important symptoms referable to the cranial nerves, 
to the cerebral peduncles, and to the arteries making up the circle of 
Willis. The syphilitic process may affect the nerves by compressing 
them ; more frequently it extends to the connective tissue of the nerve 
itself, thus setting up a neuritis. There is a great difference, however, 
as to the liability of individual nerves. The olfactory is rarely involved, 
although loss of its function, anosmia, usually bilateral, is sometimes ob- 
served. The optic nerve is frequently implicated. The ophthalmoscope 
shows an optic neuritis, usually bilateral, although generally more pro- 
nounced in one eye than the other. Or there may be a simple optic 
atrophy. Disturbances of vision dependent upon disease of the optic 
nerve occur in the form of hemianopsia, of concentric limitation of the 
visual fields, or of diminution in the acuity of central vision. 

Nerves of the Extrinsic Eye Muscles. — Oculomotor palsies are the 
most constant localizing symptoms of basilar meningitis. They are, in 
the great majority of cases, unilateral. When occurring on both sides, 
the paralysis is more severe on one side than on the other. They cause 
double vision and are responsible to some extent for dizziness and un- 
certainty of gait. All have this in common, that they undergo fluctua- 
tions. They may appear suddenly and get very much worse or very 
much better in a short space of time. None can be regarded as incurable 
if improvement begins soon enough after its first appearance. 

The third nerve is probably affected more frequently than any other 
by syphilis. The difference in the size of the pupils and the loss of pu- 
pillary reflexes, already mentioned, are due to lesions in its fibres or in 
its nuclei. In addition, palsies in the muscles which it supplies are very 
common. The nerve may be totally deprived of function, so that the 
external rectus and superior oblique are the only functionating muscles left. 
Under such circumstances there are ptosis, a marked external squint, 
and the pupil is dilated. The patient cannot turn his eye much farther 



SYPHILIS OF THE NERVOUS SYSTEM. 317 

outward than it is held by the tonic contraction of the external rectus. 
More frequently there is paresis rather than paralysis in all the muscles 
supplied by the nerve, so that movements can be performed, though im- 
perfectly ; or one muscle may be much more profoundly affected than the 
others. Thus there is often a marked ptosis without serious affection of 
the muscles of the eyeball. Third-nerve paralysis is frequently ushered 
in by ptosis, the paralysis, if it extends, involving other muscles later. 
It often exists as the only cranial- nerve lesion. 

Isolated paralysis of the fourth nerve (superior oblique) is very un- 
usual, although it does occur. The sixth nerve (external rectus), on the 
other hand, suffers frequently, either alone or in combination with other 
nerves. 

It is very rare for all the oculomotor nerves of the eye to be involved 
together. In such cases the lesion is usually chronic, acting on the 
nuclei rather than on the nerve trunks. 

Fifth Nerve. — The trigeminus is among the more infrequent of cranial 
nerves stricken by syphilis. Paralysis of it occurs, however, either alone 
or in combination with other palsies; it is almost always limited to one 
side. The sensory symptoms are the most prominent. There is dimin- 
ished sensibility or anaesthesia in the distribution of the nerve. This 
may result in ulceration of the cornea, through the lodgment of foreign 
bodies. There may be typical trigeminal neuralgia. Involvement of the 
motor root is much less common. It manifests itself by less power in the 
muscles of mastication on the affected side. 

Seventh Nerve. — One-sided facial paralysis is a common symptom of 
basal syphilis. The nerve is usually affected after its exit from the pons, 
and the paralysis therefore has the characteristic of a peripheral paralysis. 
It is usually not complete and the electrical reactions show a diminution, 
rather than a loss of faradic excitability. The acoustic, the glosso-pha- 
ryngeal, the vagus, the accessorius, and the hypoglossus nerves are hardly 
ever affected by basal syphilis. 

Peduncular Symptoms. — Associated with the cranial-nerve affections 
of basal meningitis there is frequently a loss of power in the limbs of one 
side, due to affection of one of the cerebral peduncles. This loss of 
power appears as a weakness rather than as a complete paralysis. The 
hand is clumsy, unwieldy, and weak rather than powerless; the leg is 
dragged and the patient limps, though he can still use the leg for getting 
about. This involvement of motion is usually of the spastic type, with 
increased tendon reflexes. It may be due to the pressure of small gum- 
mata upon one of the cerebral peduncles or the pons, or to arterial dis- 
ease. Its arterial origin will be considered later. 

The gummata are extensions of the meningitis along the pial septa 
which dip in between the nerve fibres and compress them. 

As in this situation the motor tract is as yet uncrossed, peduncular or 



318 VENEREAL DISEASES. 

pontine paralysis shows itself on the side opposite the lesion. But the 
cranial nerve injured by the same focus of disease has already made its 
exit from the brain axis, so that its paralysis is on the same side as the 
lesion. Consequently the clinical picture is that of crossed hemiplegia or 
paralysis of the limbs of one side, with paralysis of one or more cranial 
nerves on the opposite side. Such a disposition is the general rule. It 
has, however, occasional exceptions. 

Arterial Symptoms. — The large arteries are frequently involved in 
basal meningitis. Arteritis in the vessels in the neighborhood of the 
meningitis develops simultaneously with the inflammation of the mem- 
branes, or else occurs as a direct extension of it. In other cases, a large 
artery at some distance from the meningeal focus becomes diseased. 
When the large arterial trunks are affected, the aspects of the case are 
much more serious, for the patient is then exposed to the danger of apo- 
plectic symptoms. It will be more convenient to consider the symptoms 
under the description of primary arteritis. It is sufficient here to say 
that every patient with basal meningitis is exposed to arterial complica- 
tions, and especially to thrombosis or aneurism of the basilar and middle 
cerebral arteries. These are accidents of the later periods of the disease. 

Course. — Basal meningitis is as a rule a chronic affection. Sometimes 
the disease takes a rapid and stormy course, with intense headaches, 
vomiting, fever, convulsions, and rapidly appearing paratysis, ending in 
death perhaps in a few weeks. But such cases are unusual. Generally, 
one or two symptoms appear at a time, and go along with remissions and 
exacerbations, until recovery begins or until other symptoms are added as 
the patient gets worse. It may thus last for several months or a year. 
It may be terminated at any time, though generally not until it has existed 
for several months, by an apoplectic attack. Cases of long standing de- 
velop greater or less degrees of dementia. 

Primary Syphilitic Arteritis. 

This term applies to the cases of cerebral syphilis in which arterial dis- 
ease forms the first and most important lesion. It is extremely common. 
It may be widely distributed throughout the cerebral arteries, causing 
symptoms of general mental impairment. Its most conspicuous manifes- 
tations, however, result from the predominance of the affection, or a com- 
plication of it, in some large and important vessel, causing impairment or 
loss of one or more special brain functions. They result from a gradual 
closure due to obliterating endarteritis, or to a more sudden one, due to 
thrombosis. Thus there may be monoplegia or hemiplegia, numbness 
and tingling in limited areas or in a whole side of the body, muscular 
twitchings, epileptiform attacks, dizziness, all the varieties of aphasia, 
hemianopsia, etc. 



SYPHILIS OF THE NERVOUS SYSTEM. 319 

The symptoms may be ushered in suddenly, without warning, the 
patient having considered himself m perfect health, or there may be a 
period of weeks or months of vague warnings, such as slight numbness 
down one side, or twitchings, or difficulty in speech, or weakness in an 
arm or leg, or attacks of dizziness ; or, if the arterial disease complicates 
some pre-existing condition, it will have been preceded by symptoms of 
it. When the symptoms come suddenly, the picture is that of apoplexy. 
There may be an initial coma lasting usually not over a few hours, though 
the patient may die in it. Or, instead of coma, there may be drowsiness 
or a sudden violent pain in the head, or great dizziness, or simply a con- 
dition of mental confusion. Then follow the special localizing symp- 
toms, such as paralysis (hemiplegia usually), local spasms, aphasia, etc. 
Sometimes coma, or mental symptoms, exist without any localizing signs. 
More frequent than these cases with apoplectiform development are those 
in which, during a period of headache and mental dulness lasting several 
weeks or more, there gradually appear special symptoms to indicate a 
partial closure of some important artery. 

The diagnosis of syphilis of the cerebral arteries is of greatest impor- 
tance, especially in the cases which come on gradually. It usually oc- 
curs in young adults. Probably, when heart diseases are eliminated, 
eighty per cent of all cases of apoplexy occurring under forty years of 
age are syphilitic in origin. The headache is distinguished from other 
headaches in being worse at night. It is severe, though less severe 
than that of basal meningitis. The individual symptoms are usually im- 
perfect in their development. Thus the paralysis, though perhaps com- 
plete at first, usually improves very rapidly. In chronic cases there is 
paresis rather than paralysis. The symptoms may also be paroxysmal 
in character, worse and better on successive days. 

The two affections — basal meningitis, with its frequent complication 
of arterial disease, and primary arteritis — are the most frequent and in 
general the most clearly defined clinical types of cerebral syphilis. They 
may perfectly well be complicated by syphilitic lesions elsewhere in the 
brain. Thus a basal meningitis may extend to the cortex, or may exist 
contemporaneously with a generalized or localized cortical meningitis. 
In some cases, however, isolated syphilitic lesions exist independently of 
either of the two commoner affections. Of these the most frequent are 
meningitis over the hemispheres and gummata. 

Cortical Meningitis. 

This generally begins in the dura, extending to the pia, and then in- 
volving the subjacent brain substance. It may be either generalized or 
localized. 

1. General cortical meningitis and meningo-encephalitis due to syph- 



320 VENEREAL DISEASES. 

ills presents itself under the clinical form of headaches, dizziness, of gen- 
eral impairment of the intelligence, often going on to dementia. Localiz- 
ing signs, due to the meningitis itself, are not prominent. The condition 
is, however, generally complicated by disease in the cerebral blood-vessels, 
or it may take the form of pachymeningitis interna hsemorrhagica. Under 
such circumstances its naturally chronic course may be interrupted by suc- 
cessive apoplectic attacks. 

2. Localized cortical meningitis and meningo-encephalitis are more 
acute than the preceding. They are frequently situated over the motor 
area and parietal lobes, and consequently such localizing symptoms as 
paralysis, Jacksonian epilepsy, aphasia, etc., are common. The headache 
is localized to, or at least more intense in, the affected area, and here also 
there is tenderness on percussion over the skull. Optic neuritis may be 
present, though this is not the rule. 

The extent of the pathological process varies greatly, and consequently 
the general symptoms of brain disease, such as vomiting, dizziness, etc., 
are not the same in all cases. If the process remains localized and uncom- 
plicated, the prognosis is relatively good. 

Gummata. — Gummata of the brain may occur as extensions of local 
meningitis or may exist as isolated tumors in the hemispheres or the 
basal ganglia. They are rare in the cerebellum. They may be single or 
multiple, large or small. Their symptomology is that of brain tumors in 
general, with the special characteristics peculiar to brain syphilis. 

Syphilis and General Paresis. — General paresis, either because it is now 
recognized more readily, or else by reason of the excessive strain modern 
times put upon the nervous system, has come to be a disease of frequency 
and importance, especially in large cities. Syphilis certainly plays an 
important part in its causation. While statistics vary as to the frequency 
with which the brain degeneration is preceded by the venereal disease, 
all agree that it is great. The clinical relationship of the two diseases, 
however, is not fully substantiated by post-mortem evidence, for the brain 
of a general paralytic does not present the histological anomalies most 
characteristic of syphilis ; and the most expert pathologist, simply from 
the examination of such a brain, could not say whether the patient had 
had syphilis or not. On the other hand, the pathological changes found 
in general paresis have nothing to indicate that syphilis might not have 
caused them. 

The most rational view is that syphilis is intimately concerned in the 
production of general paresis, probably through the agency of a late (para- 
syphilitic) toxin. 

Spinal Syphilis. 

Syphilis attacking the spinal cord has many of the peculiarities already 
mentioned under brain syphilis. The symptoms vary from time to time 



SYPHILIS OF THE NERVOUS SYSTEM. 321 

and are prone to relapse. Many of them are incomplete, in the early 
stages at least. Thus, the affection of motor power is apt to be in the 
form of paresis, rather than paralysis ; one side is usually involved more 
than the other ; sensory symptoms take the form of numbness and ting- 
ling and a slight blunting of cutaneous sensibility rather than of distinct 
objective anaesthesia. There is sometimes a dissociation of sensibility in 
spinal syphilis, i.e., there may be loss of one variety of sensation with 
preservation of others. The most frequent variety of this is preserva- 
tion of the sense of touch, with impairment or loss of the senses of 
temperature and pain. The loss of rectal control is rarely present early 
in the disease ; retention of urine, on the other hand, may be pronounced 
from the first. 

About one-quarter of the cases of spinal syphilis are complicated by 
brain symptoms. These latter may be slight and inconspicuous, being 
confined to headache, slight anomalies of the pupils, the paralysis of a 
single cranial nerve, or occasional accidents indicating interference with 
the cerebral circulation. On the other hand, both brain and cord symp- 
toms may be prominent, constituting the type known as cerebrospinal 
syphilis. In this variety especially the spinal symptoms indicate multi- 
ple foci of disease. The special characters, association, and evolution of 
the symptoms of spinal syphilis vary with the type and situation of the 
lesion within the spinal canal. If the spinal-cord lesions are multiple 
and disseminated, the clinical type may be very complex. Syphilitic 
affections of the vertebrae, compressing the cord secondarily, are very rare. 
They cause a more sharply localized pain in the back and more pain on 
movement of the column than when the meninges or cord are involved 
primarily. 

The most frequent form of spinal syphilis is meningomyelitis. Its 
symptoms vary with its location, but as its favorite seat is in the mid- 
and lower dorsal regions, the commonest type of spinal syphilis is spastic 
paraplegia, with pain in the middle of the back extending down the legs. 
The course of the disease is usually chronic; rarely is the onset sudden. 
It progresses for weeks or months with intervals of arrest or improve- 
ment. It may go on until the patient is totally paralyzed, with contrac- 
tures, bed-sores, lost control of the sphincters — in short, to irremediable 
and sooner or later fatal loss of function of the spinal cord. When the 
disease is situated lower down in the cord, the type of paralysis is flaccid 
rather than spastic. When in the cervical region it may give a picture 
similar to the pachymeningitis cervicalis hypertrophica of Charcot. Then 
both arms and legs are affected. They are weak with increased tendon 
reflexes. Numbness and tingling are felt chiefly in the arms. Atrophy 
is often conspicuous in the small muscles of the hand. There are pain 
and stiffness in the neck. 

One-sided lesions cause the Brown-Sequard type of paralysis, i.e., 
21 



322 VENEREAL DISEASES. 

paralysis of motion on the side of the lesion, and disturbances of cutane- 
ous sensibility on the other side. 

In some few cases a gummatous deposit singles out some individual 
nerve root. This is especially frequent with the first dorsal. It results 
in pain in the neck, tingling, numbness or anaesthesia and pain in the 
inner side of the arm and hand, and weakness in the small muscles of the 
hand. As the cilio-spinal fibres from the sympathetic pass through this 
root, the most characteristic manifestation of its compression are a loss of 
the cilio-spinal reflex, myosis, and a sinking in of the eyeball, with nar- 
rowed palpebral fissure. 

Finally, in some cases, ataxia is the most conspicuous symptom. 

Solitary gummata, either of the dura or of the cord itself, give the 
ordinary focal symptoms of tumors of other characters in these parts. 

The Relation of Syphilis to Locomotor Ataxia. — Syphilis stands in 
about the same relation to tabes as it does to general paresis. A large 
percentage of persons who develop tabes have had syphilis. Yet there is 
nothing in the pathological anatomy of the former disease particularly 
characteristic of syphilis. Neither are tabetic symptoms cured by specific 
treatment. Yet the great frequency of the association of the two dis- 
eases leaves little doubt as to a causal relation between them. 

Prognosis of Nervous Syphilis. — When syphilis attacks the nervous 
system, two questions arise : First, What are the chances for recovery 
from the present attack? and second. What are the chances, in case of 
recovery, for future immunity? 

The answer to the first question is, that if the symptoms are recog- 
nized early enough and vigorous treatment is instituted promptly, the 
chances are very good. Paralysis of the limbs or of the cranial nerves, 
coma, aphasia, optic neuritis, bladder disturbances — in short, any or all 
symptoms — may fade away if the cause of them has not induced irrepar- 
able injury to the essential elements of the nervous system. 

If hemorrhage has occurred, or if local anaemia has gone on to 
softening, the prognosis becomes the same as for the conditions due to 
other causes. But when early danger signals, such as slight numbness, 
or thickness in speech, or headache, or twitchings, occurring in persons 
who have had syphilis, are recognized and acted upon, they usually disap- 
pear under treatment and are not, immediately at least, followed by others 
of more serious omen. Paralytic symptoms due to pressure of gummatous 
deposits may last for several weeks or even months, and then disappear 
entirely. When, however, such symptoms are the result of sudden arte- 
rial closure, and last so long a time, complete recovery is not probable. 

The prognosis in all cases of syphilis of the nervous system should be 
guarded. It is best as long as the symptoms of arteritis are absent. 
But cerebral arteritis may exist without giving symptoms until its existence 
is made plain by thrombosis or hemorrhage, which may terminate the 



SYPHILIS OF THE NERVOUS SYSTEM. 323 

case at any time. A certain number of patients do not respond to treat- 
ment, and in spite of all that may be done the disease goes on to cause 
permanent disability or death. 

As to the probability of second attacks of syphilis of the nervous sys- 
tem, statistics are unreliable. It is a disease characterized by relapses, 
and there is a certain probability that a person who has been affected by 
it once may be affected again. There is no doubt, however, that many 
patients have one attack which is properly treated and they recover and 
never have another. The liability to subsequent attacks is diminished by 
a regular life and perhaps by occasional courses of iodide. 

Treatment. — The treatment of the various symptoms of syphilis of the 
nervous system is to be carried out in accordance with the general princi- 
ples of treatment of nervous disease. A word may be added here, how- 
ever, in closing, on the special requirements of constitutional treatment. 

This should be vigorous and should consist of inunctions, rather than 
of the internal administration of mercury, and large and increasing doses 
of the iodide of potassium. The inunctions should be carefully given 
every day for five days, then interrupted a day, on which the patient 
takes a warm full bath; then resumed for five days, and so continued 
for six weeks, stopping if the gums become touched actively. At 
the same time the iodide is being taken in increasing doses. Begin- 
ning with fifteen grains three times a day, the dose is rapidly increased 
until the patient is taking two hundred or three hundred grains daily. ^ 
Even larger doses seem successful in some cases, in which smaller doses 
have failed. Gowers maintains, and correctly we think, that if no bene- 
ficial effects of this mixed treatment are observable at the end of six 
weeks, the treatment is a failure and should be abandoned. 

After an attack of nervous syphilis the patient may advantageously 
take two or three monthly courses of iodide (gr. xxx.-l. daily) every year 
for several years. 

' The senior author has given two ounces and six drachms each day for eleven 
days. 



CHAPTER XV. 

SYPHILIS OF THE GENITO-UEINAEY ORGANS IK BOTH 

SEXES. 

The Kidney. 

Syphilis is found in the kidneys as interstitial, diffuse, connective- 
tissue-cell hyperplasia, as gummy tumor, and as amyloid degeneration. 

The diffuse chronic syphilitic nephritis is similar to other forms of 
interstitial nephritis. It is more likely to occur in patches, and upon 
section small clusters and collections of cells are often found scattered 
through it. The patches of circumscribed disease become contracted and 
condensed with the progress of the affection, and the capsule adheres to 
them. They may undergo fatty degeneration in certain scattered areas. 

Gummata are not often met with in the kidney. In structure they 
resemble gummata of other organs. They are always associated with 
more or less diffuse, parenchymatous nephritis, each gumma being situ- 
ated in a condensed band of connective tissue. 

Amyloid degeneration of the kidney has in it nothing that is specific. 
It may be associated with other lesions due to syphilis, or exist alone. 
In the latter case it is the rule to find the liver also and the spleen to be 
amyloid ; but this degeneration may exist in all these organs, and yet the 
patient have no syphilis. Nevertheless, amyloid degeneration of the 
viscera is common enough in connection with late syphilitic cachexia to 
have attracted general attention ; and although the change is not in itself 
specific, it is undoubtedly in some way often due to syphilis as a cause. 

The only way in which the existence of syphilitic lesions of the kid- 
neys can be even surmised during life is by the presence of albumin in 
the urine, with or without casts, for the ordinary tissue changes in the 
organ are not attended by local pain or general fever. There may be 
symptoms of uraemia (but very seldom) and general anasarca (equally 
rare), and often there are no symptoms at all, excepting the presence 
of albumin in the urine, to declare that the kidneys are not sound. 

Many cases of albuminuria have been reported which have come on 
during the course of syphilis. They are generally unimportant, and get 
well under treatment. It is certain that in some cases slight transient 
albuminuria is produced by the prolonged use of iodide of potassium in 
large doses. This ceases on leaving off the drug. 



SYPHILIS OF THE GENITO-URINARY ORGANS IN BOTH SEXES. 325 

Syphilis of the ureter does not seem to occur. Syphilis appears also 
to spare the bladder, except in connection with disease of the spinal cord. 

The Male Genitals. 

The penis most often bears the brunt of the attack in primary syphilis 
in being the seat of chancre and lymphangitis. Later in secondary dis- 
ease, cutaneous eruptions occur upon it, and mucous patches and ulcers 
within the cavity of the prepuce and (very rarely) within the urethra. 
Relapsing indurations occur early and late in the disease at the seat of 
the primary chancre. In tertiary disease, ulcerated subpreputial gumma 
is by no means rare ; a papular eruption may occur within the urethra, 
giving rise to a gleet. 

Finally, in tertiary disease, gummata occasionally occur in the cor- 
pora cavernosa, usually in the anterior third of the organ ; they are very 
rare, and must be distinguished from chronic circumscribed inflammation 
of the sheaths of the corpora cavernosa^ and from calcification of the 
penis. 

Gumma of the corpus cavernosum is a hard, painless, semi-elastic 
swelling at first. It causes deflection of the penis when erect, toward the 
side upon which it is situated, and to an extent proportionate to the size 
of the growth. In structure it is like other gummata. It goes on to 
reach a certain size, and then may soften and shrivel away, or become 
fibrous, or possibly calcify. General calcification of the penis occurs in 
plates upon the sheath of the corpus cavernosum and is not syphilitic. 

Chronic circumscribed inflammation of the corpora cavernosa is also 
mainly superficial, confined to the sheath and underlying tissue, some- 
what painful to pressure, often advancing in one direction as it gets well 
in the other, never by any chance suppurating, occurring spontaneously 
or as a result of injury, never due to syphilis. 

The last two affections are not in the least degree helped by antisyph- 
ilitic treatment, either mercurial or by the iodides ; but gummy tumor 
promptly disappears when the latter remedy is boldly pushed in large 
doses. 

The prostate does not appear to suffer directly from syphilis. Gumma 
in this region is possible, but very rare. 

The spermatic cord is sometimes the seat of gummy tumor," and the 
scrotum a favorite locality for condylomata and scaly patches of the cir- 
cinate sort. 

1 Van Buren and Keyes : " Gen. -Urinary Diseases and Syphilis," New York, 1874, 



326 VENEREAL DISEASES. 



The Testicle. 

Epididymitis. — During secondary syphilis, in the earlier months — 
three or four after chancre — there may appear in the epididymis, usually 
at its head, on one or both sides of the body, a round, hard tumor, stand- 
ing distinct from the testicle, and not capped over it as in ordinary chronic 
epididymitis. It is attended by a slight amount of spontaneous pain, 
increased by manipulation ; occasionally the swelling is perfectly indolent, 
and the pain is never so great as that experienced in ordinary epididy- 
mitis. 

It is quite rare. It always gets well, never has been known to sup- 
purate. It is quite constant in its appearance at the globus major, and 
does not extend to the body of the epididymis or to the globus minor. 
It never involves the testicle. Later in the disease the epididymis is 
attacked in its entirety, generally by a slow and indolent syphilitic proc- 
ess. In the tertiary stage the enlargement may be general or it may be 
nodular and irregular according to the distribution of the hyperplastic 
gummatous growth. 

Treatment in the early stage is mercurial. In the advanced period 
iodide is indicated combined with mercury. Local measures are unnec- 
essary. 

Orchitis. — Syphilis of the body of the testicle in the late stages devel- 
ops in a cellular overgrowth of connective-tissue elements constituting 
diffuse syphilitic orchitis, perhaps generalized through the whole organ, 
sometimes confined to a limited area. 

Along with the other changes in the organ the tunica vaginalis becomes 
thickened, and its cavity obliterated by cohesion of its two surfaces, or 
cut up into partitions by partial adhesions. There may be a great or 
small amount of fluid in the tunic constituting a hydrocele, which may 
account for much of the swelling and must be removed before the actual 
contour of the testicle can be determined. Often a hard plate of over- 
hanging tissue with a dense angular edge can be felt. This sign is nearly 
pathognomonic. 

The result of the anatomical changes is a gradual, general enlargement 
of the organ or localized patches of induration, usually the former. After 
a time the organ atrophies and gets to be a mere fibrous knot, or, in any 
case, smaller than it originally was. 

Syphilitic orchitis is a late symptom, rarely appearing during the first 
year of the disease, and sometimes coming on long after all symptoms 
have ceased. It is also found in inherited syphilis. 

Gumma of the testicle is recognized as a distinct tumor perhaps accom- 
panying the physical changes indicative of diffuse orchitis. It is pain- 
less. The nodule grows to a certain size, then softens centrally and 



SYPHILIS OF THE GENITO-URINARY ORGANS IN BOTH SEXES. 327 

undergoes cheesy degeneration, or, infiltrating the tunica albuginea, the 
two surfaces of the tunica vaginalis adhere, and the skin becomes attached 
over the swelling mass, which opens and an abscess cavity is formed. In 
some instances the skin softens, ulcerates, and lets out the gumma with 
the contents of the testicle, constituting one form of benign fungus of the 
testicle. 

The epididymis is sometimes the seat of gummy tumor, but rarely; 
and the cord (Verneuil) also occasionally. 

The symptoms are an insidious swelling of one or both testicles with- 
out pain. Generally the patient finds out by accident that one of his 
testicles is unnaturally large and hard. Squeezing such a testicle in the 
hand causes the patient little or no pain, and the organ feels to the touch 
as hard as wood. It either preserves its oval shape when the epididymis 
is indistinguishable from the body of the testicle ; or in some instances, 
when the epididymis is also involved, this portion may be felt as a crest- 
ed overgrowth, when it has been appropriately called the " clam-shell " 
enlargement. The cord is not involved, the tunica vaginalis, instead of 
being obliterated, may be full of fluid. 

The diagnosis of syphilitic testicle is often difl&cult. There is no pos- 
sible danger of mistaking it for gonorrhoeal epididymitis, or any other 
acute inflammatory affection of the epididymis or testicle; the intense 
pain in these maladies, both spontaneously and upon handling the organ, 
excludes syphilitic testis from diagnostic consideration when it is in ques- 
tion. Nor is there any considerable chance of the error of mistaking 
chronic epididymitis, the pseudo-tuberculous testis, for syphilitic disease 
of the organ. The lumpy condition of the epididymis capping the soft 
testicle above, or hanging down as a cheesy nodule below the tail of the 
epididymis, perhaps softening into abscess and becoming fistulous, but 
leaving the soft, elastic testicle intact in its peculiar natural sensibility, 
may occasionally suggest the syphilitic epididymitis, yet its chronic course 
and peculiar pathological physiognomy will readily distinguish it from 
the syphilitic affection. 

The main difiiculties in diagnosis of syphilitic testicle are hydrocele, 
tubercle, and malignant disease of the testicle. Hydrocele is not impor- 
tant. Many syphilitic testicles are so surrounded by the fluid of a hydro- 
cele that their physical characters are entirely obscured. In no case is it 
safe to decide that a hydrocele is a simple matter until it has been tapped 
and the testicle examined. If, after tapping, the physical signs are those 
of syphilis of the testicle, no radical treatment of the effusion in the 
tunica vaginalis should be undertaken ; both because it is likely to fail 
and because it is unnecessary, since antisyphilitic treatment will remove 
the effusion together with the lesion of the testicle. 

Tuberculous testis, however, is often painless ; and certain stages of 
cancer of the testicle and of sarcoma are suggestive of syphilis. The 



328 



VENEREAL DISEASES. 



salient points of clinical difference between these affections can be best 
presented in the form of a short diagnostic table. 



Diagnostic Table. 



Sypbilitic Testicle. 



Previous History. — S y p h i - 
litic. 

Commencement. — Genera 1 1 y 
in the testicle. 

Growth. — Insidious, often 
unnoticed, may last several 
years. 

Size and Contour. — Rarely 
larger than a goose egg ; body 
of testicle hard and more or 
less smooth ; epididymis free, 
sometimes presenting "clam- 
shell" induration; scrotum 
unchanged. 

Softening and Discharge. — 
Rather exceptional ; sometimes 
occurs, leaving fungus. 

Fluid in Tunica Vaginalis. — 
Common. 

Pain and Tenderness. -r-Ah- 
sent. 

Often bilateral, simultaneous 
or consecutively. 

Sexual Power. — Diminished. 

Inguinal and Pelvic Glands. 
— Normal. 

Spermatic Cord. — Rarely 
implicated. 

Seminal Vesicles. — Normal . . 

Treatment. — Curative 



Tuberculous Testicle, 



Neoplasm. 



Tuberculous. . 

Generally in the epi- 
didymis. 

Slow ; often lasts many 
years. 

Often larger than a 
goose egg ; nodular in the 
epididymis. 



Softening and abscess 
the rule, leaving fistula. 



Not unusual . 



Insignificant, as a rule. 



Often bilateral consecu- 
tively. 

Sometimes diminished, 
often not impaired. 

Normal or tender from 
simple inflammation. 

Generally involved. .... 

Frequently diseased . . . 
Quite unsatisfactory ; 
cure possible, but slow. 



Always in the testicle. 

Sometimes slow ; some- 
times rapid. 

Sometimes enormous, 
weighing several pounds; 
sometimes lobulated; 
epididymis becomes in- 
volved ; veins of scrotum 
often enlarged. 

Sometimes ulceration, 
leaving malignant fungus. 

Unusual. 

Present as a rule, often 
very sharp ; sometimes 
painless. 

Very rarely bilateral. 

Not impaired, except by 
size and pain. 
Involved. 



Often implicated 
ard the end. 
Normal. 
Ineffective. 



tow- 



Treatment.—SjTph.ilitiG testicle in the diffuse form calls for mercury 
as well as for iodide of potassium. Local treatment is of little or no 
value, but a suspensory bandage should be used to protect the enlarged 
organs from injury. The effect of treatment is slow, but should be per- 
sisted in to save as much of the glandular structure as possible from 
atrophy. The iodide should be pushed up to large doses to the point of 
full tolerance and the effect watched. 

For gummy tumor, the iodides alone are needed, in doses as large as 
the stomach can conveniently manage. A prompt effect is to be expected. 



The Female Pelvic Organs. 

The female genitals are the common seat of chancre, erosions, and 
mucous patches. Tertiary tubercular patches are found within the vagina, 
and tertiary brawny infiltrations leading to ulcers which are very chronic 



SYPHILIS OF THE GENITO-URINARY ORGANS IN BOTH SEXES. 329 

in their course. Gummata in this region, which are rare, may perforate 
one or the other of the vaginal septa. Lancereaux describes a case of 
gummy tumor of the ovary similar to the same lesion in the testicle, and 
both he and Hutchinson have encountered some cases of imperfect sexual 
development in the female, in connection with congenital syphilis, making 
it seem probable that parenchymatous ovaritis is possible in hereditary 
syphilis, as parenchymatous orchitis and gumma of the testicle in the 
male are known to be. 

Gummata have been found in the Fallopian tubes. 

Functional derangements of menstruation are very common in women 
with syphilis. In the secondary stage, ansemia leads to scanty menstru- 
ation, the relaxed ligaments allow the organ to become easily displaced. 
Hence arise all sorts of malpositions with catarrhal states of the uterine 
cavity, dysmenorrhoea, metrorrhagia, sterility, hysteria, etc. 

The cachectic stage of tertiary syphilis also leads to uterine derange- 
ments which induce premature change of life. 

A chronic hyperplastic infiltration of the cervix is known to occur as 
a result of syphilis, which leads to a fibroid induration and stenosis of 
the OS. 

Treatment of these uterine derangements is that of the stage of syph- 
ilis in which they occur, together with such local measures as each indi- 
vidual case may call for. Certain uterine growths have disappeared 
under the treatment with iodide of potassium and mercury, but nothing 
very definite is known of syphilis of the uterus. 



CHAPTER XVL 

SYPHILIS OF THE EYE AND EAE. 

The skin of the eyelids is occasionally the seat of chancre ; patches of 
various kinds of eruption may come upon it, mucous, flat papules are not 
uncommon, and circumscribed gummata are often found in this region. 

The tarsal cartilages may be attacked by syphilitic inflammation dur- 
ing the course of the disease, producing considerable infiltration of the lid 
and lasting for weeks and months. 

Upon the conjunctiva, chancre and mucous patches have been observed. 

The lachrymal gland may become enlarged and indurated as a result 
of syphilis, but this condition is a rare one. The caruncles are the seat 
both of chancrous ulcerations and gummy tumors. 

The lachrymal sac, and the skin over it, may be the seat of gummatous 
deposit, and if this be allowed to ulcerate, lachrymal fistula may result. 
The nasal duct is frequently occluded by reason of ulcerative gummatous 
changes within the nasal cavity, especially if the lachrymal bone be in- 
volved in necrosis. 

Changes in the cornea are uncommon in acquired syphilis. With in- 
herited disease chronic interstitial keratitis is quite common. It will be 
described along with the other lesions of inherited syphilis. Chronic 
diffuse interstitial keratitis due to acquired syphilis in the adult does 
occasionally occur, the entire cornea being thickened and obscured, due 
to interstitial cellular infiltration. Another form known as punctate kera- 
titis occurs as scattered areas of corneal opacity. 

The sclera is also sometimes the seat of syphilitic inflammation and 
gummatous deposit. Two forms are spoken of, according as the super- 
ficial or deep structures are involved, viz., episcleritis and parenchymatous 
scleritis. 

The treatment of these affections consists mainly in the use of anti- 
syphilitic remedies, the protection of the eye with smoked glasses, and 
general tonics. 

In keratitis atropine instillations are also indicated. 

The iris suffers very often in acquired syphilis. 

It is probable that at least half of all the cases of iritis which occur 
are syphilitic in origin. Iritis most often comes on in severe cases of 
syphilis with one of the early eruptions ; particularly is it apt to coincide 
with a pustular eruption. The symptoms are exactly the same as those 



SYPHILIS OF THE EYE AND EAR. 331 

of acute iritis due to any cause ; slight dulness and change in the color of 
the iris, more or less injection of the pericorneal conjunctiva (possibly 
chemosis), lachrymation, supra-orbital pain, generally worse at night, 
and intense photophobia. The pupil is hazy, and will not dilate in the 
dark. When forced to dilate by the use of atropine or duboisine, its mar- 
gin is often festooned, it does not dilate regularly. Plastic exudation of 
lymph, effused from the borders and posterior surface of the iris, is quite 
common, by means of which adhesions are effected with the anterior 
capsule of the lens, and the dilatability of the pupil is permanently com- 
promised. Its opening may be entirely occluded. A thin, diffused sero- 
plastic exudation sometimes fills the anterior chamber (serous iritis). 
It may be seen to be absorbed and to melt away under treatment. 

The simplest form of iritis occurring early in the disease is spoken of 
as plastic iintis. Where the affection is more deeply seated and is accom- 
panied by cellular infiltration it is known as 'parenchymatous iritis. In 
this form suppuration may occur which often appears in scattered nodules 
or tubercles upon the surface of the iris. 

Gumma of the iris is less common, but may be observed as a small, 
yellowish-red papule growing from the iris. This may reach a consider- 
able size, fill up the pupil, and distend the anterior chamber. It may 
disappear under the internal use of the iodide of potassium. Instead 
of growing out as one distinct tumor, there may be several small gum- 
mata upon the iris, or the whole muscle may be diffusely infiltrated and 
contract strong adhesions with the capsule of the lens. 

The ciliary body and the choroid may be involved in inflammatory and 
gummatous complications in connection with syphilitic iritis. 

Relapse of plastic iritis, especially if there be many adhesions, is quite 
common, and these relapses may continue on for a number of years. 
Plastic iritis is often double, simultaneously or consecutively. Gumma- 
tous iritis is generally confined to one side. 

Treatment. — Iritis when seen early generally yields a prompt obedi- 
ence to the influence of mercury or the mixed treatment, according to the 
stage of the disease in which iritis appears. If the patient is anaemic 
and debilitated, cod-liver oil, tonics, change of air, good food, etc., are 
all of the highest value. The mercury should be pushed until the gums 
show its influence slightly. 

The great danger in iritis is adhesion of the pupillary margin to the 
anterior capsule of the lens. If this occurs, it is vastly better that it 
should do so with the pupil widely dilated ; hence it is always advisa- 
ble to use instillations of solutions of atropine into the eye. A solu- 
tion of gr. i.-iv. to the § i. of distilled water may be used; a few drops 
being placed beneath the lid once a day, or oftener, if it is found neces- 
sary, in order to hold the pupil dilated to its greatest extent, and this 
should be continued until all photophobia has passed and all conges- 



332 VENEREAL DISEASES. 

tion ceased. The eye should be kept closely shaded from light, but it is 
not wise to keep the patient in the house, much less to confine him to a 
dark room. In case of great pain hot compresses and sometimes leeches 
over the temple are employed. 

The gummatous form of iritis comes most readily under the influence 
of the iodides, but the use of atropine is desirable in these cases as well as 
in the other forms. For old cases when the pupil is adherent, and relapses 
occur, iridectomy is the remedy. 

Syphilis of the ciliary body or cyclitis is generally observed in connec- 
tion with inflammation of the iris (iridocyclitis) or of the choroid. Gum- 
mata have been known to occur in this region. 

The choroid may be affected by syphilis alone, or in connection with 
disease in other structures within the globe ; it often participates in inflam- 
matory disturbances which primarily involve the iris. Choroiditis dis- 
seminata, or plastic choroiditis, is a common form of the disease as pro- 
duced by syphilis. In this condition the ophthalmoscope reveals, through 
a clouded vitreous humor, small scattered spots of a pale color, perhaps 
with reddened borders, distributed over the posterior surface of the cham- 
ber of the eye. The retinal vessels may be occasionally seen unchanged, 
passing over these spots, which are of varied size, and are evidently ele- 
vated exudations. The optic nerve is congested. 

These elevated exudations may disappear entirely under treatment, 
leaving but little trace, or they may be succeeded by small white atrophic 
spots without pigment, except at their borders, where there is an intensi- 
fication of pigmentation in the shape of a dark line. The vitreous is 
more or less clouded with opacities. There is also a serous choroiditis 
resembling serous iritis in which the exudation is serous instead of plastic. 
A condition involving a marked increase in the cellular tissue, also seen in 
iritis, is likewise tQi'niQdi parenchymatous choroiditis. 

This affection is chronic in character. The amount of influence upon 
vision is proportionate to the position and extent of the exudative patches, 
and the degree of atrophy following them. The course of the malady is 
very chronic; it occurs in late secondary disease, and well along in the 
tertiary period. Mercurial treatment is appropriate, and, unquestionably, 
is often slowly productive of much good. In old cases, in which atrophy 
is an accomplished fact or far advanced, treatment is of little or no 
value. Local treatment is useless. The eyes should be kept protected 
from strong light. 

The retina also suffers from syphilis. Both eyes may be attacked 
simultaneously or successively. There is no outside redness upon the 
conjunctiva, no lachrymation, no pain, moderate photophobia. The only 
subjective symptoms are, in the beginning, flashes of light; later, failure 
of sight. The affection may get well and leave little or no trace, or 
may lead to permanent impairment of vision. 



SYPHILIS OF THE EYE AND EAR. 333 

The ophthalmoscope reveals a cloudy vitreous and a retina apparently 
obscured. Its outlines are less distinct than usual, the retina is cedema- 
tous, the retinal vessels, as well as the optic nerve, are hypersemic; the 
outline of the papilla is not clearly marked. The veins are full, and there 
may be hemorrhages. 

Retinitis occurs more commonly in combination with choroiditis when 
it is characterized by infiltration of the vitreous. In the forms in which 
the inflammation is distinctly confined to the retina itself there is general 
opacity of this structure with more or less hypersemia, oedema, and ecchy- 
mosis according to the intensity of the inflammation. The finer distinc- 
tions between the other forms of retinitis are too technical to come within 
the scope of this work. 

The treatment of syphilitic retinitis is by mercurials in moderate 
amount. No great energy of treatment is called for, and a cure may 
be expected if treatment is applied during the early stages of the ma- 
lady. The eyes should be shaded by colored glasses. The abstraction 
of blood, by occasional leeching of the temple, has been recommended. 

Optic neuritis is an affection very common in syphilis in connection 
with a variety of lesions of the brain. It may also originate primarily 
within the globe of the eye independently of external causes. It is very 
often found in connection with convulsive and paralytic changes due to 
syphilis, and is looked upon as a corroborative symptom of great value in 
many cases. 

The symptoms are : diminution of the field of vision, in one direction 
or another, often irregularly — a portion, perhaps an irregular half or a 
quarter of the field, being lost. A routine examination of the eyes with 
the ophthalmoscope should be made in all cases of nervous disease due to 
syphilis, especially if there be pain in the head, in order that impending 
optic neuritis may be detected early and loss of sight warded off. 

In simple, light cases of optic neuritis, the ophthalmoscope shows only 
a little indistinct blurring of the papilla, a congestion of the nerve, and 
distention of the central vessels. In severer cases, the disc is greatly 
swollen, with irregular, obscured borders. The disc seems infiltrated, 
and is of a cloudy white or grayish-red color, the vessels are distended, 
irregular, tortuous. This appearance is known as " choked disc. " It indi- 
cates intracranial pressure, as by a tumor, and is a syphilitic symptom 
only by coincidence. It occurs equally well in connection with tumors 
of the brain due to other causes. Optic neuritis is oftener double than 
single. 

The treatment of optic neuritis is the mixed treatment of tertiary 
syphilis with preponderance of the iodides. Local measures are unneces- 
sary. The effect of treatment often depends upon the promptness with 
which it is commenced and its power to remove the intracranial lesion, 
which has given rise to the trouble in the eye. The eye symptoms are 



334 VENEREAL DISEASES. 

often of only secondary importance; but improvement in the size of the 
field of vision and an arrest in the progress of the affection may be fre- 
quently attained by suitable treatment persisted in for a considerable 
time. 

Syphilis of the Ear. 

The external ear is the seat of many cutaneous lesions and ulcers in 
syphilis ; mucous patches appear sometimes in the external auditory canal, 
and a peculiar dry scaliness of this canal, with tendency to impaction of 
cerumen, is quite commonly encountered in syphilitic patients. This 
affection calls for constant care and frequent syringing of the ear to keep 
the passage in good order and the drum-head clear until the tendency to 
dry exfoliation passes away. Improving health, when the depressing 
influence of syphilis has been removed, restores the integument of the 
auditory canal to its normal condition. Gummata of the external ear are 
rare. 

The middle ear suffers in various ways by syphilis. Ulcerative and 
bony lesions within the cavity of the nose and the pharynx lead to thick- 
ening and inflammatory changes in the Eustachian tube and its mucous 
lining. These may terminate in catarrhal troubles of the middle ear 
and consequent impairment of hearing. 

Inflammation in the middle ear generally extends from syphilitic trou- 
ble in the nose or throat. It may assume a catarrhal type and lead to 
sclerosis or suppuration, periostitis, or rarefying ostitis of the bony struc- 
tures. 

The labyrinth is sometimes involved, but more commonly in inherited 
than acquired syphilis. 

The symptoms of middle-ear disease are mainly tinnitus aurium and 
impairment of hearing in various degrees. There may be no pain and 
the hearing may not be seriously affected until the disease has existed for 
a long time. Ulcerations in the nasopharynx accompanied by impair- 
ment in hearing should lead to the suspicion of catarrhal inflammation of 
the middle ear. 

The treatment consists in the employment of warm syringing, the ap- 
plication of leeches behind the ear, and inflation of the tympanic cavity. 
The mercurials internally are generally more effective than the iodides; 
but the possibility of implication of bone calls for the use of the last-men- 
tioned remedy, although not in very large doses. 

The auditory nerve, the second branch of the seventh pair, is some- 
times the seat of special disease in syphilis, aside from any loss of func- 
tion due to disease of the bones of the internal ear or gummy tumor 
involving the nerve. Such essential loss of function in the nerve has 
been observed in the secondary stage and is greatly improved by internal 
treatment. In tertiary disease it sometimes comes on suddenly without 



SYPHILIS OF THE EYE AND EAR. 335 

warning, not attended by pain, without any especial symptoms except 
that the patient becomes deaf — often very rapidly so. 

If the cochlea is involved, the high notes of the musical scale are lost 
first (Roosa), or are heard double, and the tuning-fork on the forehead is 
heard best in the sound ear. Some ringing of the ear is complained of, 
and vertigo, with staggering, are apt to usher in the disease. 

The diagnosis of syphilis, in cases of deafness coming on in this way, 
must be based upon the history and concomitant symptoms. 

The treatment must be energetic. No time is to be lost. The disease 
should be taken, if possible, at its very beginning, and opposed vigor- 
ously with specific remedies from the start. Both mercury and the iodide 
of potassium should be used, and both should be pushed rapidly to the 
point of tolerance. If possible, the mercurial bath should be employed. 
Everything in these cases must be made subservient to the treatment. 
The patient should be confined to an unirritating diet, give up business, 
and have his mind at rest. 



CHAPTER XVIL 

INHERITED SYPHILIS. 

Syphilis and Pregnancy. — Syphilis may be transmitted by inheritance. 
The question of its transmission to the child from either one or both 
parents as well as the possibility of inheritance m the third generation 
has already been discussed (page 206) . There can be no possible doubt 
that active early syphilis in the mother necessitates disease in the child, 
if the latter comes to term at all; while active early syphilis in the father 
is not incompatible with a healthy child, if the mother be not poisoned. 
After syphilis becomes latent in the parents, when they both appear to be 
healthy, the child may still be syphilitic, and repeated successive con- 
ceptions may all yield a diseased product for a number of years, the limit 
of which cannot be definitely stated. This much, however, seems certain, 
that the rule is for syphilis eventually to wear itself out, and for syphilitic 
parents eventually to produce healthy offspring, provided their own health 
has not been seriously and permanently undermined by syphilitic cachexia 
or visceral lesions. In other words, syphilis is transmitted only as syphi- 
lis. A syphilitic parent may produce a weakly child, because she has 
had her own health broken by syphilis ; but she would have produced ex- 
actly the same child had her health been broken by want and privation, 
by cancer, by malaria, by alcohol, or any other cause. Syphilis does not 
change in type by transmission. It does vary greatly, as seen in the 
child, but it varies in activity, in intensity, not in type. A child born 
to parents in active syphilis will probably die, unless its own vitality has 
been sheltered by the treatment of the mother while it was in the foetal 
state. A child born to parents whose disease is on the wane, perhaps 
nearly exhausted, shows but few evidences of disease, and those per- 
haps only during adolescence ; but what symptoms it does show bear the 
brand of syphilis, and are relievable, if at all, mainly by antisyphilitic 
treatment. 

Statistics seem to show that about one-third of the total number of 
children conceived by syphilitic parents die in utero, and of those which 
are not still-born about twenty-five per cent succumb to the disease dur- 
ing the first few months. 

Syphilitic Abortion. — When a woman is in active syphilis, she rarely 
carries a child to term. At first it is customary for such a woman to 
abort at or about the third month of utero-gestation. Such a woman may 



INHERITED SYPHILIS. 337 

have been poisoned by her husband, and had a chancre without know- 
ing it. 

Should she become pregnant again, she will again abort, but probably 
at a later month of utero-gestation. Again pregnant, she again aborts ; on 
this occasion, perhaps, miscarrying at the seventh month. The next at- 
tempt may produce a dead-born child, with its skin commencing to come 
off. Finally a child will be born at term alive, perhaps plump and clean- 
skinned, but in from two to four weeks it begins to fall away in flesh, gets 
snuffles, sore mouth, eruptions, jaundice, and dies ; another child appears 
and dies in a convulsion after a few months of life, or perishes by maras- 
mus in its second summer. At last a fat child is born seemingly healthy, 
but, as it grows, its fontanelles close too rapidly, it is microcephalic, looks 
like an old man, is perhaps very precocious, but it has a harsh cry, con- 
tracted jaws, bad teeth ; the second set are syphilitic teeth. It has a 
syphilitic countenance, and grows up, perhaps, dwarfed or deformed m 
its bones, to fall a victim, possibly, to gummatous lesions of the bones, 
the brain, the eye, or the viscera during development into manhood. 

After this the mother will produce a perfectly healthy child, if her 
own health be good. Her subsequent offspring will not probably be de- 
formed. A child may be weakly, if the mother or father, or both, be in 
poor health, or from a variety of causes; but if the parent is syphilitic, 
the child is either syphilitic or healthy, so far as the syphilis essentially 
has anything to do with the matter. 

Now, during all this time above detailed, a mercurial treatment given 
to the mother, by inunction or internally, during the whole course or 
the greater part of her pregnancy, will generally cause her to produce a 
healthy child — a child who not only is healthy at birth, but remains 
healthy, and does not require treatment. Treatment rarely has so good 
an effect if used m the first pregnancy. Then the syphilitic poison is too 
strong. A live child may be born reasonably healthy, but its health is 
not assured, and it may demand treatment to preserve it from injury by 
the development of hereditary syphilis. 

Again, if a mother has produced a healthy child under treatment, she 
must go on, and at her next pregnancy again take a full mercurial course, 
although she may have had no symptoms of syphilis during a number of 
years, or she will run the risk of again producing a diseased child. Dur- 
ing how many pregnancies this must be kept up is not known, but cases 
are on record in which the successful production, under mercury, of two 
healthy children successively (the eighth and ninth, all the previous chil- 
dren having died syphilitic) did not succeed in rendering the mother 
capable of bringing a non-syphilitic child into the world. In cases of 
this sort, therefore, it will be wiser to medicate the mother at least 
through three successive pregnancies before allowing her to try the exper- 
iment of passing through a term of utero-gestation unaided by drugs. 
22 



338 VENEREAL DISEASES. 

The cause of abortion when the mother is syphilitic is believed to be 
toxins which are generated in her system and circulated through her 
blood and which possess varying degrees of virulence according to the 
stage of the diesase and the effect of treatment. 

When the intensity of syphilis is great enough, the germ is incapable 
of development to maturity, and the foetus dies. This death of the prod- 
uct of conception is probably attended by and due to alterations in the 
placenta which destroy any resistance this organ may exercise against the 
entrance of the syphilitic toxins into the foetal circulation. The ovum 
may be blasted to such an extent that abortion of a misshapen organized 
mass occurs within a few months after conception. The syphilis of the 
parents, under these circumstances, is too apparent to need confirmation 
by any fresh proof drawn from any condition of the ovum. Attempts at 
saving the foetus must be made at each subsequent pregnancy, and the 
chances of success will improve very materially with each attempt. 

When the child has been fully formed, and then dies in utero, it is 
very uncommon for the uterus to carry it to full term. Abortion usually 
occurs about the sixth month or sooner, unless inoculation of the mother 
takes place after impregnation, when it occurs somewhat later. 

The condition of affairs described above may certainly be averted by 
treatment. Mercurial treatment is of the most value. The iodides have 
little or no power in averting the tendency of syphilitic women to mis- 
carry. Mercury will generally do this, and when it accomplishes the 
result, it does so without injury either to the child or to the mother. 

The manner of giving mercury, under these circumstances, is unim- 
portant, provided enough be given. Inunction is highly praised by some 
authorities. 

The blue mass, which is an unirritating form of mercury, is appropri- 
ately combined with a tonic in one of the following : 

I^ Pil. hydrargyri, . . . . . . . . gr. c. 

Ferri sulph. exsiccat., gr. 1. 

M. ft. pil. 1. 

Or— 

I^ Pil. hydrarg., . gr. c. 

Quinin. bisulph., gr. 1. 

M. ft. pil. 1. 

Commencing at the beginning of pregnancy, one of these pills is to be 
used after each meal (three a day) for a week. Then four pills a day are 
used for a week, then five pills a day for a week, and so on until the med- 
icine begins to disagree. When the mouth becomes a little touched, all 
medication is suspended for a week, and then a dose, two-thirds of what 
was found necessary to touch the mouth, is commenced with and given 
regularly. It may be alternated, from time to time, with a mild dose of 



INHERITED SYPHILIS. 339 

corrosive sublimate in compound tincture of bark. It may be intermitted 
entirely for a time, and replaced by inunction if the stomach becomes 
irritated. 

Such a course will save most mothers from miscarrying. The chances 
of averting the mishap are greater the farther removed the conception if 
from the chancre. Success or failure in one pregnancy must modify thi 
treatment of the next, and the result is certain to be finally satisfactory 
to all concerned. 

Milk diet, combined with the mercurial, is very advantageous in preg- 
nancy, and in any case a mild diuretic should be occasionally used. 

STMPTOMATOnOGY OF INHERITED SyPHILIS. 

When a foetus has been dead in the uterus for some time it becomes 
macerated. The epidermis rises into large bullae over portions of the 
body, or sheds off entirely in large patches. The amniotic liquid is more 
or less cloudy, discolored, sometimes putrid. In such children are found 
invariably certain pathological tissue changes in the viscera and in the 
bones, particularly the epiphyseal ends of the long bones. These changes 
are the same as those which are found (although less marked) in the 
viscera and bones in children who die of inherited syphilis at varjang 
periods after birth. The visceral changes are much the same as those 
which occur in connection with some cases of acquired syphilis, the dif- 
ference being that, with inherited disease, visceral lesions are more com- 
mon than in acquired syphilis, and that they are more often of the diffuse 
interstitial type than gummatous, as distinct tumors. Interstitial hyper- 
plastic thickening of the stroma of the liver and lungs is very common in 
inherited syphilis — so common as to be the rule in all cases dying early. 
The thymus is quite constantly involved, and the spleen and kidneys are 
very often implicated. The ordinary necrotic and carious changes, the 
subperiosteal gummata, and the ulcers involving the bone, already de- 
scribed for acquired syphilis, occur also sometimes in children with in- 
herited disease who survive ; but the lesions now about to be studied are 
found only in inherited syphilis, and are peculiar to it. They are very 
constant also, and it is said may always be found upon any dead-born 
foetus if the cause of its death has been syphilis. 

The Bones and Joints. — The symptoms of bone syphilis in inherited 
disease are a thickening at the ends of the long bones, sometimes involv- 
ing the skin in inflammatory adhesion, sometimes attended by local soft- 
ening and suppuration, sometimes having gone on to a separation of the 
epiphysis from the shaft of the bone, and given rise to an inability to use 
the limb (pseudo-paralysis — Parrot^). The bones most often diseased 



1 Archiv. de physiol. norm, et path., 1872, Nos. 3, 41 and 5. 



340 VENEREAL. DISEASES. 

are the long bones of the extremities, the ribs, the clavicles, the metacar- 
pal and metatarsal bones. The lesions are nearly always symmetrical. 

All children with inherited syphilis do not necessarily suffer with these 
bony changes, or at least, if they do, they grow np without bearing any 
evidence in their bones that they have so suffered; but, if the syphilis 
in the inherited state be intense enough to blight the ovum and cause 
the death of the foetus, then these bony changes, more or less marked, 
are constantly found. 

The changes in the bones take place at the line of cartilaginous junc- 
tion between different centres of ossification, and are most marked at the 
epiphyseal line of junction at the ends of the shafts of the long bones 
(osteochondritis). Here may be found fusiform swellings, thickening of 
the bones, and osteophytes, bony overgrowths, which may be felt through 
the skin. If the degenerative changes have advanced far enough, an epi- 
physis may be separated from its diaphysis without any preforation of the 
skin or discharge of necrotic material ; or the skin may become adherent 
and perforated, allowing the debris of bony and cartilaginous tissue, 
which much resembles gummatous material, to be discharged externally. 

All of these conditions (except the last) may be found in children dead- 
born, and, any of them, during infantile life, with or without other evi- 
dences or of syphilitic disease. They should be sought for in the foetus 
dead-born and prematurely delivered, if there be any reason to suspect 
syphilis in the parents. 

Another morbid condition, due to syphilis and described by Parrot, ^ is 
the formation of osteophytes in the anterior f ontanelle of the growing child, 
by means of which the sutures sometimes become ossified and the develop- 
ment of the cranium and of the brain interfered with, or even arrested. 

These syphilitic changes in the ends of the long bones may require 
the microscope for their detection. Often, however, the changes are 
manifest to the unaided eye. The thickening at the end of the bone may 
be felt and seen. The perforation of the skin and gummatous discharge 
can be seen and touched. The loss of function is obvious. 

It is possible to divide the minute changes into three degrees : 

In the first degree a layer of osteophytic growth may envelop the bone, 
sometimes making it so thick as to double its diameter. The epiphyseal 
cartilage is also thickened. The cartilage cells become hypertrophied. 
Increased proliferation takes place within them, and the cartilage becomes 
prematurely infiltrated with earthy salts. 

In the second degree there is premature calcification of the intercellu- 
lar substance and arrest of true bony formation. 

In the third degree there is softening, and inflammatory changes take 
place. 

The exact histological nature of the morbid process does not seem to 

> Ibid. 



INHERITED SYPHILIS. 341 

be invariably the same, although the changes always take place in a line 
between the proliferating and the hypertrophic zone of the cartilage, as 
shown by Haab/ 

Wegner^ looks upon the process as an osteochondritis beginning in 
the cartilage. He believes that the vascular supply through the vessels 
becomes deficient, through a too rapid deposit of bone salts on the one 
hand, while the proliferating cartilage cells, on the other hand, make a 
stagnating zone between the proliferating cartilage and the medullary 
spaces of the diaphysis. 

Others have pronounced the process to be the formation of a syphilitic 
granulation tissue, growing out from the medullary prolongations of the 
diaphysis into the cartilage, and there falling into softening which leads 
to a shedding of the epiphysis. 

The pathognomonic value of these changes in the ends of the long 
bones is very great, since no one has yet claimed to have found them pro- 
duced by a cause other than syphilis, and they may therefore be largely 
instructive as to the cause of death in obscure cases, in which repeated 
miscarriages take place, and the existence of syphilis in the parents is 
not on any other account suspected. 

Periostitis also attacks the bones of syphilitic children, notably the 
long bones, and is a later manifestation than the previously described 
condition, generally occurring after the child walks about. 

Syphilitic lesions of the joints assume the same type as in the acquired 
form. 

Syphilitic dactylitis occurs in the early period of hereditary syphilis, 
involving swelling of the phalanges and metacarpal bones, sometimes 
invading the joints. The cha.racters of these lesions resemble those of 
acquired syphilis, under which heading they are described. 

The treatment of syphilitic children upon whom these lesions exist is 
very effective. It should be a mixed treatment, mercury being used by 
inunction, and the iodide of potassium given internally in repeated doses 
well diluted, commencing with a very small dose (half a grain or less for 
an infant) and increasing it steadily but slowly, as it is tolerated, until a 
dose producing an obvious effect is reached. A dose somewhat smaller 
than this maximum dose may be continued for some months after the child 
has recovered from all local evidences of progressive disease. 

The visceral lesions of hereditary syphilis are generally more severe 
than in the acquired disease. 

A child born alive with inherited syphilis^ may have its lungs so 

^ Virchow's Archiv, vol. Ixv. ^Ibid., vol. 1. 

3 Acquired syphilis (for example, vaccinal syphilis) is very serious, and often 
rapidly fatal in the infant; but it is similar to acquired syphilis in the adult, in 
that the visceral lesions only come on after a longer or shorter period of secondary 
eruptions. 



342 VENEREAL DISEASES. 

stiffened with interstitial, syphilitic, cellular changes that it cannot 
breathe sufficiently to support life. Its liver may be solid with parenchy- 
matous changes, and it may grow visibly yellow and expire in a few days 
or weeks, without any especial symptoms on the skin or mucous mem- 
branes. 

On opening the abdomen of a child dead with inherited syphilis, an 
enormous liver is often found, which has imdergone infiltrating changes 
at the expense of the normal glandular structure. It is hard, tense, 
elastic. A piece of it, cut out, slips away when pinched between the 
thumb and finger. It may be so dense that the finger can bore a hole 
in it only with difficulty. Collapsed and thickened vessels show on the 
pinkish-brown surface of section as white knots, from which radiate thin 
whitish streaks. The organ is the seat of diffuse interstitial hepatitis. 

In inherited disease, the spleen may be larger and harder than usual, 
but gummata are rarely found in it. Eisenschutz^ thinks that enlarge- 
ment of the spleen, easily detected by palpation, is a diagnostic symptom 
of latent inherited syphilis. 

Digestion may be interfered with by the induration of the pancreas, 
which Birch- Hirschf eld ^ found to be so common in his autopsies of chil- 
dren dead with inherited syphilis. Occasionally a child dies in convul- 
sions without any surface signs of syphilis. 

Ordinarily, however, when a syphilitic child is born alive, even if it 
happens to be plump and fresh-looking for the first few days, very char- 
acteristic changes soon begin to show themselves. The face grows thin 
and old-looking. If there have been any eruptive phenomena at birth 
(excoriated, papular, scaly patches), these increase in number and extent. 
If the skin was intact at birth, it begins to show livid patches, which run 
on to become papular or pustular; or excoriations of livid color, and cracks 
and fissures appear, with pimples, boils, abscesses, and other lesions. 
Condylomata and ulcers at the anus are very common. The skin comes 
off from the fingers and is shed from the palms and soles in large patches ; 
sometimes the nails come off. Mucous patches, fissures, and ulcers ap- 
pear about the mouth. In fact, the child with hereditary syphilis is sub- 
ject to all the lesions of the skin and mucous membrane which appear in 
the acquired form (Fig. 105) . They are liable to be more diffuse and more 
severe. Catarrh involves the nostrils and the child gets the snuffles, the 
nostril caking up to the point of complete obstruction, so that the child 
finds it difficult or impossible to nurse. 

Meantime the voice grows husky, hoarse. The child cries in a fright- 
ened, explosive way, or moans its life out in croaking sobs. Dry, tear- 
less, pitiful crying is sometimes the method the poor little sufferer takes 

^"Das latente Stadium der hereditaren Syphilis," Wien. med. Wochenschrift, 
48, 49, 1873. 

2 Archiv f. Heilkunde, February, 1875. 



INHERITED SYPHILIS. 



343 



to announce his distress ; but he soon becomes marasmic, and death cures 
him of his pains. 

If by careful nursing and active treatment he pulls through, he may 




Fig. 105, — Inherited Syphilis. Polymorphoiis eruption. (After Kaposi, Morrow.) 

become marasmic later, or be stunted in his growth, perhaps weakly in 
constitution, possibly hydrocephalic. During his early life he may have 
disease in his bones, ulcers, gummata in different positions, ocular trou- 



344 VENEREAL DISEASES. 

bles ; indeed, he is exposed to a long series of disorders, which, if not 
controlled by antisyphilitic treatment, make life a burden and lead to de- 
struction of tissue, to deformity, to loss of function in various important 
organs. 

On the other hand, a child may entirely recover, and, after a reason- 
ably prolonged treatment, grow up to good health and become as vigorous 
as any one. Such children, nevertheless, may have syphilitic teeth and 
be stamped with the syphilitic countenance for life. 

The date of appearance of syphilitic symptoms upon children with 
inherited disease, who are born apparently in perfect health (as often 
happens), is very variable. Statistics taken in lying-in hospitals make 
the most common period about the second three weeks of life. Occasion- 
ally children grow up to be several months old before symptoms show 
themselves, and these symptoms may be quite light and be overlooked. 
Fournier has a case in which inherited syphilis appeared at the age of 
twenty-five; Zambaco has one at twenty-six; Bulkley one at twenty- 
three, and another at twenty -four; Dron one at twenty. 

This possibility of the appearance of lesions due to hereditary syphilis 
late in life must be constantly kept in mind, or mistakes are quite certain 
to be made, to the grave detriment of the patient. 

The following are important external manifestations of hereditary 
syphilis : 

Syphilitic Pemphigus. — Flattened bullae, varying in size from that of 
a small split-pea to that of a penny, situated upon a red base with a red 
areola and containing a thin sero-pus, are sometimes found scattered over 
the surface of syphilitic children at their birth, or coming out in crops 
shortly after birth. This is the pemphigus of the new-born ; it is nearly 
always syphilitic in nature. It is said of the infantile pemphigus not 
syphilitic that it always first attacks other parts of the body, appearing 
later upon the palms and soles, while true syphilitic pemphigus starts 
always in the last-mentioned localities, and may indeed remain confined 
to them. The bullae burst and show excoriated, livid surfaces beneath, 
or dry up into greenish-yellow crusts. 

Children so intensely syphilitic as to have this eruption very rarely 
recover under any treatment. Mercury by inunction is most suitable. 

The Syphilitic Countenance. — Certain physical traits of countenance, 
marked more or less strongly in different cases, are commonly enough 
encountered, upon growing children with inherited syphilis, to be consid- 
ered pathognomonic of the disease. They constitute what Mr. Hutchin- 
son calls the syphilitic countenance, and are striking enough to attract 
attention and to put an observant physician upon the track of syphilis in 
many cases before he has asked the patient a single question. A child 
with inherited syphilis does not necessarily have the syphilitic counte- 
nance. Many children, unmistakably syphilitic by inheritance, bear no 



INHERITED SYPHILIS. 



345 



marks that distinguish them from healthy children. One child in a fam- 
ily may be marked, and all born later may escape. 

lu a child somewhat stunted in growth, perhaps looking pinched in all 
its physical contour, or squared and dwarfed in stature, generally with an 
abnormal intelligence running to precocity which delights its parents, or 
to a stolid stupidity suggestive of idiocy 
— such a patient, a growing boy or 
girl, without any positive ulcers, or 
nodes, or other lesions indicative of 
syphilis, will be found often to have a 
coarse skin, with the pores more marked 
than usual. His color will not be 
ruddy, but sallow, dead-looking, dry, 
or perhaps greasy. His face will look 
flattened out, rather devoid of expres- 
sion, prematurely old, grave, perhaps 
anxious. His forehead is rounded and 
prominent, like that of a hydrocephalic 
child. The eyes are often small, the 
nose is undeveloped, particularly at the 
bridge, which remains broad and sunken 
as it was in babyhood. The corners of 
the mouth are often puckered with ci- 
catrices, representing old ulcers at the 
angles ; other scars may mark the mu- 
cous membrane lining the cheeks, and 
the throat may exhibit the ravages of 
past ulceration. Such a child is apt 
to have constant chronic nasal and 
pharyngeal catarrh. With this physi- 
ognomy the syphilitic teeth are apt to ^-^- 106. 
be found, and marks of old iritis, choroiditis, or interstitial keratitis, 
and more or less deafness, are rather the rule than the exception. 

Fig. 106 represents very fairly the syphilitic countenance, together 
with scars of ulcers, nodes, overgrown and irregular bones, and the general 
ungainly shape of a girl who has suffered severely from inherited syphilis. 

Syphilitic and Mercurial Teeth. — Hutchinson, in his " Illustrations of 
Clinical Surgery," London, 1876, has described and figured, with copious 
illustrations, the effects of syphilis in modifying the shape of the central 
incisors of the upper jaw, as well as the changes in the teeth produced 
by the use of mercury during their forming stage. Mercurial teeth are 
very often found in the mouth along with syphilitic teeth, and the mer- 
curial teeth were generally considered to be also syphilitic until Hutch- 
inson clearly pointed out the distinction between them. 




346 



VENEREAL DISEASES. 




Fig. 107. 



The true syphilitic " test teeth, " as Hutchinson calls them, are the 
two central incisors in the upper jaw, the teeth of the permanent set. 
The milk teeth do not show this typical peculiarity of structure, and no 
other teeth can be relied upon to indicate the presence of hereditary syph- 
ilis, excepting the two above mentioned. The first set of teeth may be 
chalky, and fall into rapid caries ; the second set may also be very defect- 
ive, falling rapidly into caries, some of them stunted in growth, some of 
them placed crosswise or altogether out of place in the mouth ; but none 
of these peculiarities are essentially syphilitic. On the other hand, a 

child may be markedly syphilitic 
by inheritance, and yet its teeth be 
perfectly sound. 

The " test teeth " are found only 
in connection with inherited syphi- 
lis. The two central incisors are 
smaller than natural, and usually 
converge somewhat (Fig. 107), or 
diverge a little. The cutting bor- 
der is narrower than the base of the tooth, making it peg-shaped, and 
along the lower edge uniformly indented with a single broad notch, as 
shown in the plate. 

These single broad notches are the features of the teeth which stamp 
them as syphilitic. The serrations at the cutting border of the incisor 
teeth, produced by a number of shallow notches, mean nothing so far 
as syphilis is concerned. They are seen not infrequently upon all the 
incisors, of the lower jaw particularly. Irregular notches, even in the 
centre of the upper central permanent incisors, are not pathognomonic ; 
and peg-shaped teeth, or teeth uneven in any respect, or badly placed or 
seamed or discolored, have no value as indicating antecedent syphilis. 
The " test teeth, " as above described, are caused by syphilis, and are not 
caused by anything else so far as has yet been discovered. 

Generally, when the edge of the notched tooth is thin, it chips off, and 
wears down with advancing life, and finally loses its characteristic appear- 
ance. 

Mercurial teeth illustrate the effect of the excessive use of mercury — of 
mercurial stomatitis upon the permanent teeth. The teeth most plainly 
marked by mercurial stomatitis are the first (the anterior) molars. The 
incisors and the canine teeth suffer. The bicuspids escape. The mer- 
curial tooth is deficient in enamel, covered with ridges and spines of 
exposed dentin, dirty-looking, and apt to become promptly carious. 
Quite often only the half of the tooth farthest removed from the gum is 
unhealthy, the half nearest the gum preserving its enamel in a smooth 
and reasonably white condition. The grinding surface of the molars is 
involved in the affection. Very naturally the influence of mercury is also 



INHERITED SYPHILIS. 347 

often shown upon the typical syphilitic teeth, but this is accidental, and 
by no means essential. 

Hutchinson states that other forms of stomatitis may also produce this 
change upon the permanent teeth, but it is more marked and more com- 
mon after mercurial stomatitis. 

Interstitial Keratitis. — The cornea is frequently the seat of a chronic 
interstitial inflammation in cases of inherited syphilis. The affection is 
most common between the ages of six months and three years, most com- 
mon of all during second dentition, but may be observed during adoles- 
cence. Occasionally it is encountered in acquired syphilis. 

The affection comes on insidiously, with slight peripheral cloudiness 
of the cornea advancing toward its centre, attended by moderate photo- 
phobia and more or less of a pericorneal zone of subconjunctival hyper- 
semia. Sometimes the symptoms become quite intense. The cornea grad- 
ually grows quite white, and sight may become so reduced that only the 
difference between light and darkness can be perceived. The cornea may 
become soft and fluctuating in spots by diffuse infiltration of pus. Ulcera- 
tion is uncommon, or very superficial if it occurs. 

Gradually, as the malady gets well, the whiteness disappears from 
the periphery toward the centre, leaving sometimes clouded spots behind. 
The iris, the choroid, and the ciliary body may be involved in inflamma- 
tion during the course of the disease. 

Both eyes may be involved consecutively. The affection in each eye 
lasts from a few months to more than a year. Relapse is possible. 

Treatment. — Hygiene and dietetics form an essential part of the treat- 
ment in these cases. Cod-liver oil, tonics, and change of air are of great 
service. Treatment by mercurial inunction is of the most value, or mild 
internal mercurial preparation may be used, due attention being paid to 
the digestion. The course must be persevered in persistently, with con- 
fidence of ultimate success in preserving vision, if the general health re- 
mains good. 

Local treatment is of some assistance, but not so valuable as the gen- 
eral measures. Warm fomentations in the beginning of the affection are 
recommended, and instillations of a solution of atropine are of consider- 
able advantage, especially in those cases in which the iris is threatened or 
involved in inflammation. 

In inherited syphilis the ear suffers in two ways. There may arise, 
in a child with inherited syphilis, a catarrhal condition of the middle ear 
which is very obstinate, and likely to result in inflammatory adhesions of 
the ossicula and permanent impairment of hearing. 

Internal mercurial treatment, with cod-liver oil, and plenty of suit- 
able food, constitute the best measures to be employed against this affec- 
tion, in combination with change of air, syringing of the external and 
inflation of the internal ear. 



348 VENEREAL DISEASES. 

Deaf-mutism sometimes occurs in children with inherited syphilis who 
have been born with perfect capacity for hearing. Jonathan Hutchinson 
has called attention to a loss of hearing which may come on very suddenly, 
sometimes quite slowly, in children with inherited disease, after they have 
begun to talk, but before the age of puberty. This affection is apparently 
an essentially nervous malad;y, not attended by any pain. There is no 
evidence to prove that the lesion is inflammatory. Treatment is of little 
or no value in these cases, and their pathology is not understood. 

Treatment of Inherited Syphilis. 

In the chapter upon the general treatment of syphilis, great stress 
was laid upon the fact that mercury was a natural antidote to syphilis, 
more or less useful in all its stages, most valuable in its power of keeping 
the disease in check, and very certainly possessed of ability gradually to 
eliminate the disease and retard relapses of symptoms. In tertiary forms 
of syphilis, however, mercury was accorded only a second rank among 
remedies, the preparations of iodine, notably the different iodides, taking 
the lead. 

In inherited syphilis all the stages of the disease come together, as it 
were. The child is born already permeated through and through with 
syphilis, and possessing at the same time visceral and bony changes due 
to tertiary alterations of tissue and secondary phenomena, in the shape 
of excoriations, papules, pustules. The discharges from many of these 
lesions are essentially and actively contagious. 

In inherited disease, notwithstanding these pathological facts, the 
iodides can usually be dispensed with, except when dealing with the late 
lesions of adolescence and bone lesions occurring during childhood. Com- 
monly, all the good that can be obtained from treatment may be derived 
from a persistent use of mercury, not pushed to the extent of producing 
salivation. 

Salivation is very difficult to produce in young infants. Excess of 
mercury given to them generally runs itself off by the bowels. Just be- 
fore, and during the period of second dentition, especial care is necessary 
in the use of mercury, in order to avoid causing enough stomatitis to give 
rise to mercurial teeth. 

Mercury is introduced into the circulation of syphilitic children pref- 
erably through the skin. The only obstacle to this is extensive ulceration 
of the surface (and even this does not preclude the possibility of dusting 
the skin with calomel), or the existence of so great an irritability of the 
integument, that the local use of mercury cannot be borne. This, how- 
ever, is exceptionally uncommon. The advantage of administering mer- 
cury by the skin is that it spares the child's stomach for food. At no 
period of life is it so essential that the stomach should be unhindered in 



INHERITED SYPHILIS. 349 

the performance of its function as during babyhood. Another excellent 
reason for employing inunction upon babies is, that it is often impossible 
to say whether they get enough mercury if the stomach is relied upon, 
and valuable time may be lost in this uncertainty. Some babies vomit 
more or less after each feeding, and are constantly regurgitating between 
their repasts, and whether all of a powder or potion given internally stays 
down or not is sometimes a matter of great uncertainty. 

If inunction is decided upon, twenty grains of mercurial ointment may 
be rubbed daily into a different part of the child's integument, the dose 
being regulated by the intensity of the symptoms and the age and vigor 
of the child. A better plan than this, although it is dirtier, is to spread 
upon the flannel belly-band of the child a thick patch of blue mercurial 
ointment, and bind it against the integument, removing it daily, and 
washing the skin well with warm water and soap. 

If any eruption or mercurial erythema appears at the site of the mer- 
curial application, a new spot should be selected, and the irritated skin 
washed with a delicate toilet soap and abundantly powdered, while a 
piece of old linen should be worn under the binder, between it and the 
impending mercurial eruption. While the belly is recovering, the legs, 
thighs, feet, and arms may be used for inunction or for the continued 
application of ointment upon bandages. 

By this too much mercury can hardly be used. As soon as the snuffles, 
the eruptive lesions, and the restlessness of the child begin to mend per- 
ceptibly, the quantity of inunction or of the ointment bound upon the 
surface may be diminished ; but the treatment must be kept up steadily 
in a mild way in some form or other, certainly as long as through the 
period of the second dentition. 

If for any other reason it is deemed advisable to use mercury internally 
instead of by inunction, the gray powder, mercury with chalk, is a prepa- 
ration sanctioned by long usage. This may be administered in powder, 
commencing with one-sixth to one-quarter of a grain two or three times a 
day, and working up the dose rapidly or slowly according to the intensity 
of the symptoms, until the latter show signs of yielding or the bowels 
are irritated by the drug. 

In the latter case it is better to diminish the dose or to substitute 
inunction, or, in some cases, when a continuance of a large dose is very 
desirable, the bowels may be quieted by the internal use of mild doses of 
opium. This, however, will very rarely be called for. 

A good way of producing a rapid effect of mercury upon a child is to 
dissolve a half grain of corrosive sublimate in six ounces of water, and to 
give a teaspoonful of this hourly for the first day, then every two hours, 
finally every three hours or at longer intervals, unless it obviously dis- 
agrees. 

This watery solution has absolutely no taste. The child who will spit 



350 VENEREAL DISEASES. 

out a powder will take this solution, believing it to be water. The medi- 
cine will mix with milk without turning it, or with any food in such a 
way that its presence is unsuspected ; and if the whole or a portion of a 
given dose should be regurgitated by an infant, it is not a very serious 
matter, since the doses follow each other in such quick succession. 

The average interval between the doses should be three to four hours 
for prolonged treatment, the intervals being shortened when a prompt or 
vigorous mercurial influence is desired. Mercurial stomatitis is not 
likely to occur with the use of this remedy in this way, and intestinal dis- 
turbance is equally uncommon — plenty of warning being given by premon- 
itory symptoms before any explosion comes on, so that there is time to 
avert the latter. 

Iodide of potassium may be administered through the milk of the 
mother, or in mild doses by the mouth of the infant, provided the dose 
be given with the food and be itself considerably diluted with water. 

In no case should a child born of syphilitic parents, whether it shows 
evidences of inherited disease or not, be allowed to suckle a healthy wet- 
nurse. The risk of infecting the latter is too great to be overlooked. A 
syphilitic child may, however, suckle its mother with advantage, and can 
never infect her (Colics' s law), even although she be considered healthy 
and has never shown any symptom of syphilis. The same rule applies to 
a wet-nurse. A syphilitic woman may have recovered and may secrete 
good milk, and such milk is perfectly suitable for the child, while the 
latter cannot poison the nurse. 



INDEX. 



Abdominal lymphatic glands, syphilis 

of, 310 
Abortion, syphilitic, 336 
Abortive treatment of gonorrhoea, 26 
Abscess in epididymitis, 99 
of Cowper's glands, 71 
of follicles of urethra, 68 
of prostate, 73 
periprostatic, 73, 75 
Alopecia, syphilitic, 288 

treatment, 289 
Antiphlogistic method of treating gonor- 
rhoea, 25 
Anus, chancre of, 214 
Argonin in acute urethritis, 33, 34 
Arteries, syphilis of, 202, 311 
Arteritis, primary syphilitic, of the 
brain, 318 
diagnosis of, 319 
symptoms of, 319 
Aspiration of bladder for impermeable 

stricture, 151 
Astringent injections, 26 
Atrophy of testicle after epididymitis, 99 
Auditory nerve, syphilis of, 334 
Auto-inoculation of chancroid, 172 
Azoospermia as a sequel to epididymitis, 
100 

Bacteria of non-specific urethritis, 8 

Bacteruria, 95 

Balanitis and posthitis, 54 

complications of, 54 

diagnosis and treatment, 55 
Basal meningitis, syphilitic, 315 
Bladder, aspiration of, 151 
Bone, gumma of, 299 
Bones, syphilis of, 297 
Brain, syphilis of, 315 
Bronchi, syphilis of, 304 
Bubo, chancroidal, 193 
cause of, 192 

indolent, 195 

simple, 194 



Bubo, simple, symptoms of, 194 
treatment of, 196 
syphilitic, 217 
virulent, 195 

treatment of, 196 
Bursse, syphilis of, 293 

Cartilage, syphilis of, 301 
Cerebral syphilis, 315 (see Syphilis) 
Chancre, course of, 214 

excision of, 213 

herpetiform, 212 

Hunterian, 212 

induration of, 214 

mixed, 212 

of anus, 214 

of fingers, 213 

of general integument, 212 

of lip, 213 

of nipple, 213 

of tongue, 213 

of tonsil, 213 

of urethra, 213 

phagedaena of, 213 

treatment of, 218 

varieties of, 211 
Chancroid, 167 

auto-inoculation of, 171 

clinical history of, 174 

complications of, 186 

definition of, 167 

description of, 167 

diagnosis of, 177 

duration of, 176 

etiology of, 169 

follicular, 168 

inoculability, 171 

manner of contagion, 173 

pathological histology, 169 

phagedenic, 187 

gangrenous, 188 
serpiginous, 186 
treatment, 189 

situation, 175 



352 



INDEX. 



Chancroid, treatment, 179 

varieties, 168 
Chancroids, anal and rectal, 184 
of fingers, 185 
of margin of prepuce, 184 
Changes in the cornea due to syphilis, 

330 
Chetwood's method of irrigating the ure- 
thra, 30 
Choc en-retour, 206 
Chordee, 15 

treatment of, 24 
Circumcision, 62 
Cock's operation, 152 
Condylomata (see Venereal warts) 

lata, 268 
Congenital stricture, 107, 115 
Constitutional syphilis, 220 (see Syphilis) 
Continuous dilatation in the treatment of 

stricture, 131 
Contracture of the neck of the bladder, 88 
Copaiba, balsam of, in urethritis, 22 
Copaibal erythema, 23 
Copper sulphate in chronic urethritis, 

48 
Cortical meningitis, syphilitic, 319 
Cowper's glands, abscess of, 71 
inflammation of, 70 
symptoms, 71 
treatment, 72 
Cowperitis, 70 
Cubebs in urethritis, 23 
Cystitis, gonorrhoeal, acute and chronic, 
89 
symptoms, 91 
treatment, internal, 92 
local, 94 

Dactylitis, 295 
diagnosis, 297 
treatment, 297 
Digestive tract, syphilis of, 305 
Dilatation, continuous, in the treatment 
of stricture, 131 
progressive, in the treatment of stric- 
ture, 125 
rapid, in the treatment of stricture, 
134 
Divulsion, treatment of stricture by, 143 
Dressings of the penis in urethritis, 34, 
35 

Ear, syphilis of, 334 



Electrolysis, 125 

Endoscope, topical applications by means 

of, 51 
Endoscopic examination of the urethra, 

26, 139 
Epididymitis, chronic relapsing, 104 
operation for, 104 
gonorrhoeal, 96 

complications and sequelae, 99 
symptoms, 97 
treatment, 101 
Erythematous patches of mucous mem- 
branes, syphilitic, 284 
syphilide, 264 
Excision of chancre, 218 
External perineal urethrotomy, 145 (see 

Perineal section) 
Extravasation of urine, 152 
symptoms of, 153 
treatment of, 153 
Eye, non-specific affections and gonor- 
rhoeal rheumatism, 159 
treatment, 160 
syphilis of, 330 

Female pelvic organs, syphilis of, 328 

Fingers, chancre of, 213 

Follicles of urethra, inflammation of, 78 

treatment, 69 
Follicular abscess of the urethra, 68 

prostatitis, 72 
Fumigations, mercurial, 242 (see Syphi- 
lis) 

General paresis and syphilis, 320 
Gonococcus of Neisser, 7, 9, 10. 

cultivation of, 7, 9 

Gram test for, 9, 11 

identification of, 10 

pseudo-, 7 

staining of, 11 
Gonorrhoea, abortive treatment of, 26 

(see Urethritis) 
Gonorrhoeal ophthalmia, 160 

diagnosis and prognosis of, 161 

symptoms of, 161 

treatment of, 162 
rheumatism, 157 

diagnosis, 158 

symptoms of, 157 

prognosis of, 158 

treatment of, 158 



INDEX. 



353 



Gram's method of staining, 9, 11 

solution, 11 
Gumma of bone, 299 

of iris, 331 

of skin, 282 

of tongue, 305 
Gummatous ulcers of mouth and. fauces, 

286 
Gummata of brain, 320 

of lungs, 305 

Haik, syphilis of, 288 
Heart, syphilis of, 310 
Herpes progenitalis, 66 

diagnosis and treatment, 57 
Herpetiform chancre, 212 
Hot Springs of Arkansas, 226 
Hunter i an chancre, 212 
Hydrocele, chronic, after epididymitis, 

100 
Hypodermatic treatment of syphilis, 244 

(see Syphilis) 

Incubation period of syphilis, 211 
Induration of chancre, 214 
Inflammatory phimosis, 59 

stricture, 107 
Inherited syphilis, 336 

symptomatology of, 339 
treatment of, 348 
Inoculability of chancroid, 171 
Instillations in chronic prostatitis, 84 

in chronic urethritis, 45 
Integument, chancre of, 212 
Internal urethrotomy, 134 
Intestines, syphilis of, 307 
Inunctions, mercurial, 239 (see Syphilis) 
Iodide preparations in treatment of syph- 
ilis, 251 (see Syphilis) 
lodism, 253 
Iris, gumma of, 331 

Irrigation treatment of urethritis, 29, 45 
Irrigations, rectal, in chronic prostatitis 
and vesiculitis, 85, 88 

urethral and intravesical, 28 

Janet's method of irrigation, 28 
Joints, syphilis of, 294 

Keratitis, interstitial, in inherited 

syphilis, 347 
Keyes' tonic treatment of syphilis, 235 
Kidney, syphilis of, 324 
23 



Larynx, syphilis of, 302 
Ligation of vas deferens for chronic re- 
lapsing epididymitis, 106 
Lip, chancre of, 213 
Liver, syphilis of, 309 
Local treatment of chronic urethritis, 
43 

treatment of acute specific and non- 
specific urethritis, 25 
Locomotor ataxia and syphilis, 322 
Lungs, gummata of, 305 

syphilis of, 304 
Lymphangitis, chancroidal, 186, 192 

syphilitic, 217 
Lymphatic glands, syphilis of, 287 

Macular syphilide, 264 
Male genitals, syphilis of, 325 
Meatus, method of cutting, 134 
Meningitis, basal, syphilitic, 315 

affections of cranial nerves in, 

316 
arterial symptoms in, 318 
course of, 317 

peduncular symptoms in, 317 
cortical syphilitic, 319 
Mercurial fumigation in treatment of 
syphilis, 239 
inunctions in treatment of syphilis, 

242 
teeth, 346 
Micro-organisms of the anterior urethra, 
7 
resembling the gonococcus, 8 
Mixed chancre, 212 

treatment for syphilis, 257 
Mouth and fauces, gummatous ulcers of, 

286 
Mucous membranes, syphilis of (see 
Syphilis) 
patches, 284 
Muscles, syphilis of, 292 

Nails, syphilis of, 289 

Neisser, gonococcus of, 7, 9 

Nervous system, syphilis of, 312 

Neuralgia of testicle after epididymitis, 
100 

Nipple, chancre of, 213 

Non-specific affections of the eye com- 
plicating urethral infiammation, 159 

Nose, syphilis of, 302 



354 



INDEX. 



OESOPHAGUS, syphilis of, 307 
Onychia, syphilitic, 289 (see Syphilis of 
the nails) 
treatment, 290 
Ophthalmia, gonorrhoeal (see Gonorrhoeal 

ophthalmia) 
Optic neuritis, syphilitic, 333 
Organic stricture, 107 
Osteocopic pains, 297 
Osteoperiostitis, syphilitic, 298 

Papular syphilide, 265 
Papulo-squamous syphilide, 267, 272 
Paraphimosis, 60 

treatment of, 61 
Parenchymatous prostatitis, 73 
Pericowperitis, 70 
Perineal section with a guide, 146 

without a guide, 150 
Periurethral inflammation, 69, 71 
Permanganate of potassium irrigations, 

32, 43, 45 
Phagedsena of chancre, 213 
Phimosis, chancroidal, 186 
complicating balanitis, 56 
inflammatory, 59 
Pigmentary syphilide, 271 
Posthitis (see Balanoposthitis) 
Progressive dilatation in the treatment of 

stricture, 125 
Prostate, abscess of, 73 
Prostatitis, acute, 72 

diagnosis of, 75 

follicular, 72 

parenchymatous, 73 

symptoms and course of, 74 

treatment of, 76 
chronic, 77 

diagnosis of, 80 

symptoms of, 78 

treatment of, 83 
Prostatorrhoea, 77, 79 
Protargol in acute urethritis, 33, 34 

in chronic urethritis, 49 
Pustular syphilide, 269 
Pustulo-bulbous syphilide, 277 



Raw erosion (chancre), 211 
Rectum, gummatous infiltration 

308 
Reinfection, syphilitic, 208 
Respiratory system, syphilis of, 302 



of, 



Retrograde catheterism during perineal 

section, 152 
Rheumatism, gonorrhoeal (see Gonorrhceai 

rheumatism) 
Roseola, 264 (see Erythematous syphilide) 
Rupial syphilide, 277 

Salivation, 245 

Sandalwood, oil of, in urethritis, 21 
Sclerosis of tongue, syphilitic, 305 
Seminal vesicles, inflammation of, 86 
vesiculitis, acute and chronic, 86 
Silver compounds, topical use of,, in acute 
urethritis, 32 
instillations of, in chronic urethritis, 
45, 49 
Skin, gumma of, 282 
syphilis of, 261 
Spasm, urethral, 107 (see Stricture) 
Spasmodic stricture, 107 (see Stricture) 
Specific treatment of syphilis, 232 
Spermatocystitis (see Seminal vesiculi- 
tis) 
Spermatorrhoea, 82 
Spinal syphilis, 320 
Spleen, syphilis of, 310 
Stages of syphilis (see Syphilis) 
Sterility after epididymitis, 100 
Stomach, syphilis of, 307 
Stricture of the urethra, 107 
acquired, 107 
annular, 113 
congenital, 107, 115 
fibrous, 113 
inflammatory, 107 
inodular, 113 
large calibre, 114 

diagnosis, 120, 122 
linear, 113 
organic, 107, 110 
etiology, 110 
diagnosis, 118 
location of. 111 
symptoms, 116 
treatment, 120 
resilient, 127 
small calibre, 114 
diagnosis, 122 
soft, 113 
spasmodic, 107 
time of development of, 111 
traumatic, 107, 116 



INDEX. 



355 



Stricture, traumatic, treatment, 110 
Superficial ulceration (chancre), 212 
Suprarenal capsules, syphilis of, 310 
Swelled testicle (see Epididymitis) 
Syphilide, erythematous, 264 

macular, 264 

palmar and plantar, 274 

papular, 265 

papulo-squamous, 267, 272 

pigmentary, 271 

pustular, 269 
tertiary, 279 

pustulo-bulbous, 277 

rupial, 277 

superficial ecthymatous, 270 

tubercular, 275 

vesicular, 271 
Syphilides, 263 

absence of subjective symptoms with, 
262 

cicatrices of, 263 

color of, 262 

form and distribution of, 262 

polymorphism of, 261 

scabs and ulcers of, 263 

tertiary, 277 
Syphilis, 198 

and pregnancy, 336 

cerebral, 315 

constitutional, 220 

course of, 199 

definition of, 198 

general pathology of, 201 

general treatment, 224 
hygienic, 227 

incubation, 211 

inherited, 336 

symptoms of, 239 
treatment of, 348 

local treatment, 247 

methods of contagion, 203, 207 

of the arteries, 202, 311 

of the bones, 297 

of the bronchi , 304 

of the bursse, 293 

of the cartilage, 301 

ot the digestive tract, 305 

of the ear, 334 

ot the eye, 330 

of the female pelvic organs, 328 

of the hair and nails, 288 

of the heart, 310 



Syphilis of the intestines, 307 
of the joints, 294 
of the kidney, 324 
of the larynx, 302 

non-ulcerative laryngitis, 303 

ulcerative laryngitis, 303 
of the liver, 309 

diffuse syphilitic hepatitis, 309 

gummatous hepatitis, 309 
of the lungs, 304 
of the lymphatic glands, 287 
of the male genitals, 325 
of the mucous membranes, 249, 284 

erythematous patches, erosions, 
284 

mucous patches, 284 

mucous patches, treatment, 250 

scaly patches, 285 
of the muscles, 292 
of the nervous system, 312 

causation, 312 

pathology, 312 

prognosis, 322 

treatment, 323 
of the nose, 302 
of the oesophagus, 307 
of the pancreas, 309 
of the peritoneum, 309 
of the rectum, 307 

chronic hyperplastic infiltration, 
308 

gummatous infiltration, 308 

ulcerations, 308 
of the respiratory system, 302 
of the skin, 261 
of the spleen, 310 
of the stomach, 307 
of the tendons and aponeuroses, 293 
of the testicle, 326 
of the thymus, suprarenal capsules, 
and abdominal lymphatic glands^ 
310 
of the tongue, 305 
of the trachea, 304 
of the vascular system, 310 
of the viscera, 302 
primary lesion, 211 (see Chancre) 
prognosis of, 208 
spinal, 320 
stages of, 220 

symptoms attending the general out- 
break of, 222 



366 



INDEX. 



Syphilis, transmission of, 203 

to third generation, 207 
treatment, general, 224 

hygienic, 227 

hypodermatic, 244 

iodide preparations, 251 

local, 247 

mercurial fumigations, 242 

mercurial inunctions, 239 

mixed, 257 

specific, 232 

tonic, 235 
Syphilitic alopecia, 288 
bubo, 217 

duration of, 218 

treatment of, 218 
countenance in inherited disease, 344 
node, 298 
optic neuritis, 333 
pemphigus in inherited disease, 344 
poison, secretions which contain, 203 
reinfection, 208 
roseola, 264 
teeth, 345 
tertiary ulcer, 281 

Teeth, mercurial, 346 

syphilitic, 345 
Tendons and aponeuroses, syphilis of, 

293 
Tertiary pustular syphilide, 279 

syphilides, 277 

ulcer, syphilitic, 281 
Testicle, abscess of, with epididymitis, 
99 

atrophy of, after epididymitis, 99 

neuralgia of, after epididymitis, 100 

syphilis of, 326 
Thallin sulphate in chronic urethritis, 

47 
Thymus, syphilis of, 310 
Tongue, chancre of, 213 

gumma of, 305 

sclerosis of, 305 

syphilis of, 305 
Tonic treatment of syphilis, 236 
Tonsil, chancre of, 213 
Trachea, syphilis of, 304 
Transmission of syphilis, 203 
Traumatic stricture of urethra, 107, 116 
Tubercular syphilide, 275 
Turpentine in urethritis, 24 



TJlceration, chancroidal, 168 
chancrous, 212 
tertiary syphilitic, 281 
Urethra, chancre of, 213 

endoscopic examination of, 26, 39 
illumination of, 39 
injections of, 26 

irrigation of, in urethritis, 29, 45 
of anterior, 28 
of posterior, 31 
micro-organisms of, 7 
Urethral and intravesical irrigation, 28 
fever, 154 

follicles, inflammation of, 68 
spasm (spasmodic stricture), 107 
Urethritis, acute, specific and non-spe- 
cific, 3 
bacteriology of, 7 
definition and etiology, 3 
diagnosis of, 17, 18 
■ duration of, 18 
symptoms of, 13 
treatment of, 19 
treatment, internal, 20 
treatment, local, 25 
chronic, 37 

diagnosis, 38 
etiology, 37 
pathology, 37 
symptoms, 38 
treatment, internal, 42 
treatment, local, 43 
Urethrocystitis, 89, 92 
Urethrorrhoea ex libidine, 81 
Urethroscopy, 39 

Urethrotomy, external perineal, 145 
with a guide, 146 
without a guide, 150 
internal, 134 
Urinary fever, 154 

treatment of, 156 
fistula, 153 
Urine, extravasation of, 152 

Vas deferens, ligation of, for chronic re- 
lapsing epididymitis, 106 
Vegetations (see Venereal warts) 
Venereal warts, 58 

treatment for, 59 
Vesicular syphilide, 271 

Warts, venereal, 58 

treatment, 59 



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Bodenhamer, William, M.D., 

Professor of the Diseases, Injuries, and Malformations of the Rectum, Anus, and Genito-Urinary 
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TREATISE ON THE HEMORRHOIDAL DISEASE. Giving its 
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Surgeon to the Children's Hospital and the Samaritan Hospital ; Assistant Professor of Ortho- 
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Lovett, Robert W., M.D., 

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A TREATISE ON ORTHOPEDIC SURGERY. Second Revised 
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Bramwell, Byrom, M.D., F.R.C.P. Ed., F.R.5. Ed. 

DISEASES OF THE SPINAL CORD. Third Edition, illustrated 
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Broadbent, Sir William H., Bart., /Vl.D. Lond., F.R.5., 

r.rV'V^** •» and 

Broadbent, John F. H., M.A., M.D. (Oxon.), M.R.C.P. 

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Brouardel, P., M.D. Paris. 

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Buck, Albert H., fl.D., 

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A TREATISE ON DISEASES OF THE EAR. Together with a 
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A VEST-POCKET MEDICAL DICTIONARY. Embracing those 
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Cabot, Richard C, M.D., 

Boston, Mass. 

A GUIDE TO THE CLINICAL EXAMINATION OF THE BLOOD 
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THE SERUM DIAGNOSIS OF DISEASE. This book aims to bring 
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Campbell, Harry, M.D., B.S. Lond. (London). 

RESPIRATORY EXERCISES, in the Treatment of Disease, Notably 
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Carpenter, Wm. B., C.B., fl.D., LL.D. 

THE MICROSCOPE AND ITS REVELATIONS. 8vo. Vol. L, 
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Cheyne, W. Watson, M.B., F.R.S., F.R.C.S. Lond. 

THE OBJECTS AND LIMITS OF OPERATIONS FOR CAN- 
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Clarke, A. Campbell, M.D., F.F.P.S.Q., * 

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Clarke, J. Jackson, M.B. Lond., F.R.C.5., 

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ORTHOPEDIC SURGERY, a text-book of the Pathology and Treat- 
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Coleman, Warren, M.D., 

Professor of Materia Medica, Cornell University Medical School, etc., etc. 

A SYLLABUS OF MATERIA MEDICA. This book is an attempt to 
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Collins, Joseph, M.D., 

Professor of Nervous and Mental Diseases in the New York Post-Graduate Medical School ; Visiting 
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THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM • 
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Cory, Robert, M.A., M.D. Cantab., F.R.C.P. Lond., 

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LECTURES ON THE THEORY AND PRACTICE OF VACCINA- 
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Dana, Charles L., A.M., M.D., 

Professor of Nervous and Mental Diseases in the New York Post-Graduate Medical School, and in 
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TEXT-BOOK OF NERVOUS DISEASES. Being a Compendium for 
the Use of Students and Practitioners of Medicine. Fourth edition, 
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Delafield, Francis, M.D., 

Professor of Pathology and Practical Medicine, College of Physicians and Surgeons, New York. 

STUDIES IN PATHOLOGICAL ANATOMY. Volume I., treating 
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Volume II. : Broncho-Pneumonia, Chronic Phthisis, Lobar Pneumonia, 
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6 PUBLICATIONS OF WILLIAM WOOD & COMPANY. 

Delafield and 

Prudden, T. flitchell, HD., 

Professor of Pathology and Director of the Laboratories of Histology, Pathology, and Bacteriology, 
College of Physicians and Surgeons, Columbia College, New York. 

A HANDBOOK OF PATHOLOGICAL ANATOMY AND HISTOL- 
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De Meric, H., Paris. 

DICTIONARY OF MEDICAL TERMS. (English-French.) This 
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DICTIONNAIRE DES TERMES DE MEDECINE. (FranQais- 
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Draper, John C, M.D., LL.D., 

Professor of Chemistry in the Medical Department, University of New York, and of Physiology 
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A PRACTICAL LABORATORY COURSE IN MEDICAL CHEM- 
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Dwight, Thomas, A.fl., fl.D., 

Instructor in Topographical Anatomy and Histology in Harvard University ; Fellow of the 
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FROZEN SECTIONS OF A CHILD. Fifteen full-page lithographic 
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Eccles, A. Symons, M.B., London. 

Member Royal College of Surgeons, England ; Fellow Royal Medical and Chirurgical Society, etc. 

THE PRACTICE OF MASSAGE ; THE PHYSIOLOGICAL EF- 
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DIFFICULT DIGESTION DUE TO DISPLACEMENTS. One vol- 
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PUBLICATIONS OF WILLIAM WOOD & COMPANY. 



L 



Einhorn, Max, M.D., 

Adjunct Professor Clinical Medicine, New York Post-Graduate Medical School ; Visiting Physician 
to the German Dispensary, and to the Montefiore Home for Chronic Invalids. 

DISEASES OF THE STOMACH. Second revised edition. Complete 
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Ellis, George Viner, fl.D., 

Professor of Anatomy in University College, London ; and 

Ford, Q. H., Esq. 

ILLUSTRATIONS OF DISSECTIONS. In a series of original colored 
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Ewart, William, M.D. Cantab., F.R.C.P. Lond., 
M.R.C.S. Eng., 

Physician to St. George's Hospital, and to the Belgrave Hospital for Children ; formerly Assistant 
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THE PULSE SENSATIONS : A STUDY IN TACTILE SPHYG- 
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GOUT AND GOUTINESS AND THEIR TREATMENT. One 

volume of 601 pages, 8vo, muslin, $4.00 net 

Finger, Ernest, fl.D., 

Docent at the University of Vienna. 

GONORRHOEA: being the translation of " Blennorrhoea of the Sexual 
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Fox, George Henry, A.M., M.D., 

Professor of Diseases of the Skin in the College of Physicians and Surgeons, Columbia University, 
New York, etc., etc. 

SKIN DISEASES OF CHILDREN. The work is based upon a series 
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Freyer, P. J., M.A., M.D., M.Ch., 

Surgeon Lieutenant-Colonel, Bengal Army (retired). 

THE MODERN TREATMENT OF STONE IN THE BLADDER 
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8 PUBLICATIONS OF WILLIAM WOOD & COMPANY. 

Qarrigues, Henry Jacques, A.M., M.D., 

Obstetric Surgeon to the Maternity Hospital ; Physician to the Gynecological Department of the 
German Dispensai-y ; Fellow of the American Gynecological Society ; Fellow of the New York 
Obstetrical Society, etc. 

DIAGNOSIS OF OVARIAN CYSTS BY MEANS OF THE EX- 
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Qemmell, Q. H., F.I.C., F.C.S. Ed. 

CHEMICAL NOTES AND EQUATIONS, INORGANIC AND OR- 
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Qowers, W. R., M.D., 

Assistant Professor of Clinical Medicine in University College ; Senior Assistant Physician to 
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EPILEPSY AND OTHER CHRONIC CONVULSIVE DISEASES. 
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DIAGNOSIS OF THE DISEASES OF THE BRAIN AND SPINAL 
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Qrandin, Egbert H., M.D., 



Chairman Section on Obstetrics and Gynecology, New York Academy of Medicine ; Obstetric 
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Gunning, Josephus H., M.D., 

Instructor in Electro-Therapeutics, New York Post-Graduate Medical School and Hospital ; 
Gynecologist to Riverview Rest for Women ; Electro-Gynecologist, Northeastern Dispensary, etc. 

PRACTICAL TREATISE ON ELECTRICITY IN GYNECOLOGY. 

Illustrated. 8vo, muslin, 180 pages, $1.75 net. 

Hamilton, Frank Hastings, A.M., M.D., LL.D., 

Professor of the Practice of Surgery, with Operations, and of Clinical Surgery, in Bellevue Hospital 
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THE PRINCIPLES AND PRACTICE OF SURGERY. Illustrated 
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954 pages. In muslin, $4.00 7iet. 

Heitzmann, Louis, M.D. (New York). 

URINARY ANALYSIS AND DIAGNOSIS by Microscopical and 
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I 



PUBLICATIONS OF WILLIAM WOOD & COMPANY. 9 

Heiferich, H., M.D., 

Professor at the University of Greifswald. 

AN ATLAS OF FRACTURES AND DISLOCATIONS. Translated 
from the Third Revised German Edition by Jonathan Hutchinson, 
Jr., F.R.C.S., London. This volume deals with fractures and disloca- 
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page colored plates. 130 pages of text, containing 126 illustrations. 
8vo (5^x8}4 inches). Muslm, uniform with other volumes of the 
series,. $3.00 net. (Wood's Medical Hand Atlases ) 



Herman, Q. Ernest, fl.B. Lond., F.R.C.P., 

Obstetric Physician to and Lecturer on Midwifery at the London Hospital ; Consulting: Physician- 
Accoucheur to the Tower Hamlets Dispensary ; Examiner in Midwifery to the Universities of 
London and Oxford : Late President of the Obstetrical Society of London and of the Hnnterian 
Society ; Formerly Physician to the General Lying:-in Hospital and to the Eastern District of the 
Royal Maternity Charity, and Examiner in Midwifery to the Royal College of Surgeons. 

DISEASES OF WOMEN ; A CLINICAL GUIDE TO THEIR 
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DIFFICULT LABOR : A Guide to its Management for Students and 
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Herrick, Clinton B., M.D., Troy, N. Y. 

Lecturer in Clinical Surgery, Albany Medical College; Attending Surgeon to the Troy Hospital and 
the House of the Good Shepherd; Consulting Surgeon to the Leonard Hospital; Surgeon to the 
Delaware and Hudson, and theFitchburg Railways; President of the New York State Association 
of Railway Surgeons, etc., etc. 

RAILWAY SURGERY. A handbook on the management of injuries. 
The only book on the subject. There has long been a demand for a work 
devoted to the surgery of cases resulting from railway accidents. This 
demand the present volume will, it is believed, supply. The book is 
clear, concise, and practical. The very numerous illustrations, which 
have all been made specially for the work, are from photographs taken 
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Holden, Luther, fl.D., 

Ex-President and Member of the Court of Examiners of the Royal College of Surgeons of England ; 
Consulting Surgeon to Saint Bartholomew's and the Foundling Hospitals ; assisted by 

Shuter, James, F.R.C.S., n.A., fl.B. Cantab., 

Assistant Surgeon to the Royal Free Hospital ; late Demonstrator of Physiology, and Assistant 
Demonstrator of Anatomy, at Saint Bartholomew's Hospital. 

HUMAN OSTEOLOGY. Comprismg a Description of the Bones, with 
Delineations of the Attachments of the Muscles, the General and Micro- 
scopic Structure of Bone and its Development. Sixth edition. With 
sixty-six full-page lithographic plates, and eighty-nine wood-engravings 
8vo, 285 pages, muslin, $1.00 net. 



lo PUBLICATIONS OF WILLIAM WOOD & COMPANY. 

Household Practice. 

See WOOD'S HOUSEHOLD PRACTICE. 

Hudson, E. D., Jr., A.fl., fl.D., 

Professor of General Medicine and Diseases of the Chest in the New York Polyclinic ; Physician to 
Bellevue Hospital, etc. 

A MANUAL OF THE PHYSICAL DIAGNOSIS OF THORACIC 
DISEASES. 8vo, 162 pages, profusely illustrated. Muslin, $1.25 net. 



Hutchinson, Jonathan, F.R.S. 

THE PEDIGREE OF DISEASE. Being Six Lectures on Tempera- 
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Ingals, E. Fletcher, A.M., M.D., 

Professor of Laryngology and Practice of Medicine, Rush Medical College ; Professor of Diseases of 
Throat and Chest, Northwestern University Women's Medical School ; Professor of Laryngology 
and Rhinology, Chicago Polyclinic, etc. 

LECTURES ON THE DIAGNOSIS AND TREATMENT OF DIS- 
EASES OF THE CHEST, THROAT, AND NASAL CAVITIES. 
Including Physical Diagnosis and Diseases of the Lungs, Heart, and 
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Kaposi, Dr. Horiz, 



Professor of Dermatology and Syphilis, and Chief of the Clinic and Division for Skin Diseases in the 
Vienna University. 

PATHOLOGY AND TREATMENT OF DISEASES OF THE 
SKIN. For Practitioners and Students. Translation of the latest Ger- 
man edition. 8vo, 684 pages, 84 illustrations, and a colored plate, mus- 
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Kellogg, Theodore H., A.M., H.D., 

New York, Late Superintendent, Willard State Hospital ; former Physician-in-Chief of the New York 
City Asylum for the Insane, etc., etc. 

A TEXT-BOOK ON MENTAL DISEASES, for the Use of Students 
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PUBLICATIONS OF WILLIAM WOOD & COMPANY. ii 



Keyes, Edward L., M.D., 

Consulting Surgeon to the New York City Hospital ; Consulting- Surgeon to Bellevue Hospital, etc., 
etc. 

and Chetwood, Charles H., M.D., 

Visiting Surgeon to Bellevue Hospital, etc. 

VENERP^AL DISEASES. Their Complications and Sequels. 
One volume of 364 pages, 8vo, illustrated by numerous drawings and 
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Kirchhoff, Dr. Theodore, 

Physician to the Schleswig Insane Asylum and Privat-Docent at the University of Kiel. 

HANDBOOK OF INSANITY FOR PRACTITIONERS AND STU- 
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Kirkes' Handbook of Physiology. 

HANDBOOK OF PHYSIOLOGY. By W. Morrant Baker, F.R.C.S., 
and Vincent Dormer Harris, M.D. Lond F.R.C.P. Fifteenth 
American Edition. , 

Thoroughly revised by Warren Coleman, M.D., late Professor of 
Physiology in the Woman's Medical College, New York; Instructor in 
Materia Medica and Therapeutics and in Clinical Medicine, Cornell 
Medical College, New York; Physician to the City Hospital, New 
York, etc., etc., and Charles L. Dana, A.M., M.D., Professor of 
Nervous and Mental Diseases in the New York Post-Graduate Medical 
School, and in Dartmouth Medical College ; Visiting Physician to 
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One volume of 856 pages, 8vo, illustrated with a colored plate and five 
hundred and sixteen illustrations, in black and numerous colors, muslin, 
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Knies, Max, M.D., 

Professor Extraordinary at the University of Freiburg. 

THE EYE AND ITS DISEASES, IN RELATION TO THE DIS- 
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NoYES, M.D. 8vo. 470 pages, illustrated, muslin, $3.50 net. 

Landau, Prof. Dr. Leopold, and 

Landau, Dr. Theodor, 

Berlin. 

THE HISTORY AND TECHNIQUE OF THE VAGINAL RADI- 
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Arthur E.Giles, M.D., London. One volume, octavo, with numer- 
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12 PUBLICATIONS OF WILLIAM WOOD & COMPANY. 

Ling, P. He. 

SYSTEM OF MANUAL TREATMENT AS APPLICABLE TO 
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Liveing, Robert, A.M. and M.D. Cantab., F.R.C.P. Lond. 

Lecturer on Dermatology to the Middlesex Hospital Medical School ; lately Physician to the 
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A HANDBOOK ON THE DIAGNOSIS OF SKIN DISEASES. 
One volume, i6mo, 266 pages, muslin, $1.00 net. 

NOTES ON THE TREATMENT OF SKIN DISEASES. One 
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Loomis, Alfred L., M.D., LL.D., 

Professor of Pathology and Practical Medicine, in the Medical Department of the University of the 
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A TEXT-BOOK OF PRACTICAL MEDICINE. One handsome 8vo 
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Eleventh edition. Muslin, $5.00 net ; leather, $5.75 uet. 

LESSONS IN PHYSICAL DIAGNOSIS. Eleventh revised edition. 
Revised by Alexander Lambert, M.D., New York. One volume, 
353 pages, 8vo, illustrated by numerous engravings in black and colors, 
muslin, $2.50 net. 

Luff, Arthur P., M.D., B.Sc, F.R.C.P. Lond. 

GOUT; ITS PATHOLOGY AND TREATMENT. The subject of 
diet has been carefully dealt with, and a classification of the various 
mineral waters is given according to their therapeutic value in the 
treatment of the various forms of gout. One volume, 256 pages. 
Muslin, $1.75 7iet. 

Macfarlane, A. W., M.D., 

Fellow of the Roypl College of Physicians, Edinburgh ; Fellow of the Royal Medical and Chirurgical 
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INSOMNIA AND ITS THERAPEUTICS. 8vo, 302 pages, musHn, 
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Macnaughton= Jones, H., M.D., M.Ch. 

PRACTICAL MANUAL OF DISEASES OF WOMEN AND UTER- 
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illustrated by 565 wood-engravings. Muslin, $4.^0 net. 

Manson, Patrick, M.D., LL.D. Aberd. 

Physician to the Seaman's Hospital Society, attached to the Branch Hospital; Lecturer on Trop- 
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TROPICAL DISEASES: A MANUAL OF THE DISEASES OF 
WARM CLIMATES. Octavo, 623 pages, illustrated, and with full- 
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PUBLICATIONS OF WILLIAM WOOD & COMPANY. 13 

Matthieu, A., 

Physician to the Pai'is Hospitals. 

TREATMENT OF THE DISEASES OF THE STOMACH AND 
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Ziegler, Ernst, 

Professor of Pathological Anatomy and of General Pathology in the University of Freiburg. 

TEXT-BOOK OF GENERAL PATHOLOGY. Translated from the 
Ninth German edition, under the editorship of Albert H, Buck, M.D., 
New York, by a select corps of specialists. Royal 8vo, 618 pages, with 
542 illustrations in black and numerous exquisite tints, and a chromo- 
lithographic plate. Muslin, $5.00 net ; leather, $5.75 net. 

Ziemssen, H. von, M.D. Munich. 

CYCLOPEDIA OF THE PRACTICE OF MEDICINE. By Vari- 
ous Authors. Complete in twenty volumes, royal Svo. A, few sets 
left. Write for prices. 



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